Final report on El Faro

https://media.defense.gov/2017/Oct/01/2001820187/-1/-1/0/FINAL PDF ROI 24 SEP 17.PDF

The Board holds the Captain primarily responsible and says they would have issued criminal charges had he survived. They said he misread the storm and overestimated his ship's ability and failed to monitor and prepare for heavy weather.

They recommend civil, but not criminal, penalties against TOTE including charges over not replacing a safety officer and crew rest periods and working hours.

They've also proposed 31 safety regulations and 4 administrative.

While I can't argue with their findings on the Captain, I find the failure to hold TOTE or anyone in their organization criminally responsible extremely disappointing. They could have prevented this. I consider the absence of preventing it a crime not that much short of the one of captaining into it. He either the company or the captain made better judgments, this wouldn't have happened and the fact there is a culture and environment leading to Captains feeling the pressure that leads to such decisions is their fault as well. I do believe in holding Corporations more responsible.

BandB said:

https://media.defense.gov/2017/Oct/01/2001820187/-1/-1/0/FINAL PDF ROI 24 SEP 17.PDF

The Board holds the Captain primarily responsible and says they would have issued criminal charges had he survived. They said he misread the storm and overestimated his ship's ability and failed to monitor and prepare for heavy weather.

They recommend civil, but not criminal, penalties against TOTE including charges over not replacing a safety officer and crew rest periods and working hours.

They've also proposed 31 safety regulations and 4 administrative.

While I can't argue with their findings on the Captain, I find the failure to hold TOTE or anyone in their organization criminally responsible extremely disappointing. They could have prevented this. I consider the absence of preventing it a crime not that much short of the one of captaining into it. He either the company or the captain made better judgments, this wouldn't have happened and the fact there is a culture and environment leading to Captains feeling the pressure that leads to such decisions is their fault as well. I do believe in holding Corporations more responsible.

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I agree. They should hold TOTE accountable criminally. All they did want open the door for the families of those lost to sue TOTE for wrongful dead. That is the norm in most case like this. Big money walks criminally but pay out to families which is pennies when talking about a life.

If they would start putting these Nutters on trial and in jail Captains would not feel the need to take the risk to run through or around storms. It is a bloody shame!

Cheers.

H.

The captain's job includes the final decision for risk assessment. His first responsibility is for the safety of the crew and passengers. Based on his knowledge of the ship's condition and the weather, nobody was in a better position to make a go / no go decision. He failed. The responsibility mostly rests on his shoulders. Simple question, do you think he would have gone if he thought he had a 1 in 4 chance of the ship sinking? There was clearly risk; he misjudged it.

Ted

For several reasons, that make sense, the vessel’s Captain holds any and all responsibility for the operation, safety and sea worthiness of the vessel. As a crew member you either have faith in the captain or you don’t go.
My dad was a captain of a working two man tugboat. He was asked by the company to perform a certain job. He told the office that under the current conditions it was dangerous and he refused. They asked a second captain on another tugboat and he accepted the task. End result, the tugboat sank in the swift current and the deckhand drowned.
Don’t work for a captain you don’t trust.

What a cop out and complete disappointed by the USCG! Makes me sick. Just like the Deepwater Horizon, don't put blame where blame should fall!

hfoster said:

I agree. They should hold TOTE accountable criminally. All they did want open the door for the families of those lost to sue TOTE for wrongful dead. That is the norm in most case like this. Big money walks criminally but pay out to families which is pennies when talking about a life.

If they would start putting these Nutters on trial and in jail Captains would not feel the need to take the risk to run through or around storms. It is a bloody shame!

Cheers.

H.

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Except they're pulling out an ancient law to minimize the amount they can be sued for. So the payout is relatively small.

SaltyDawg86 said:

What a cop out and complete disappointed by the USCG! Makes me sick. Just like the Deepwater Horizon, don't put blame where blame should fall!

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Salt, you are sailing on large commercial vessels and have better insight on this subject than most of us.

From what I have read, it appeared to me that the pressure on Captains from corporate personnel was a factor as others have also noted, so it appears you have the same opinion.

Fletcher500 said:

Salt, you are sailing on large commercial vessels and have better insight on this subject than most of us.

From what I have read, it appeared to me that the pressure on Captains from corporate personnel was a factor as others have also noted, so it appears you have the same opinion.

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I will go to my grave believing the office said sail or lose your job. I'm not the only one with this opinion.

I've been there, the bottom dollar is always on the office mind.

The facts don't support a finding of criminality by the company. The Board got it right. Further, the expensive effort to retrieve the data recorder added nothing of consequence to the findings.

Rufus said:

The facts don't support a finding of criminality by the company. The Board got it right. Further, the expensive effort to retrieve the data recorder added nothing of consequence to the findings.

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Hahahahahahaha........

When the ship sailed, I don't think the storm was considered a major risk. If so they could have stuck to the Fla east coast and Cuba north coast. Instead they stuck to planned route and went right into the storm. And the storm rapidly intensified. Storm motion was hard to predict.

I don't see fault with the company. All on the master. Cavalier attitude heading into the storm with a rather old ship. Stayed in bed til what, 4AM?? That alone is telling.

SaltyDawg86 said:

I will go to my grave believing the office said sail or lose your job. I'm not the only one with this opinion.

I've been there, the bottom dollar is always on the office mind.

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I don't believe they outright said that, but I do believe there was continual job pressure and the company was too interested in Alaska to even pay attention. Read the part where not one person in the company was even following the El Faro or the storm. Not one. The person assigned responsibility was in Washington working on the build of the new ships.

I do believe the captain was wrong, regardless of the pressure. However, I believe TOTE was also very much at fault. Either TOTE or the Captain could have said no and saved the lives. They both failed to do so. The key factors in both were a combination of money and not paying enough attention as to what was going on.

One other key element, in my opinion, there was no independent person or agency for those aboard the vessel to contact and raise their concerns and alarm. This is also pointed out in the board's report.

There are so many things pointed out about how TOTE was handling or not handling things. The place I differ from the report is on whether those things rose to a level of being criminal. The board says they weren't intentional so didn't. I look to other criminal charges such as depraved indifference. You can be criminally liable for acts or omissions that you knew or should have known had the likelihood of serious consequences.

Ski in NC said:

When the ship sailed, I don't think the storm was considered a major risk. If so they could have stuck to the Fla east coast and Cuba north coast. Instead they stuck to planned route and went right into the storm. And the storm rapidly intensified. Storm motion was hard to predict.

I don't see fault with the company. All on the master. Cavalier attitude heading into the storm with a rather old ship. Stayed in bed til what, 4AM?? That alone is telling.

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If you don't see fault with the company, then you haven't read the report. Read it and get back to us on that statement. They even used the word of the vessel operating autonomously, basically saying they had no one watching or tracking the vessel or the storm and felt no obligation to do so.

BandB said:

Except they're pulling out an ancient law to minimize the amount they can be sued for. So the payout is relatively small.

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As I said. Pennies for a life and it is the norm. When Fitzgerald sank in 1975 this is what the companies did, which I am sure TOTE will do to limit their payout to the families.

Under maritime law, ships fall under the jurisdiction of the admiralty courts of their flag country. As Fitzgerald was sailing under the U.S. flag, even though she sank in foreign (Canadian) waters, she was subject to U.S. admiralty law.


With a value of $24 million, Fitzgerald's financial loss was the greatest in Great Lakes sailing history.


In addition to the crew, 26,116 long tons (29,250 short tons; 26,535 t) of taconite sank along with the vessel.


Two widows of crewmen filed a $1.5 million lawsuit against Fitzgerald's owners, Northwestern Mutual, and its operators, Oglebay Norton Corporation, one week after she sank. An additional $2.1 million lawsuit was later filed.


Oglebay Norton subsequently filed a petition in the U.S. District Court seeking to "limit their liability to $817,920 in connection with other suits filed by families of crew members."


The company paid compensation to surviving families about 12 months in advance of official findings of the probable cause and on condition of imposed confidentiality agreements.


Robert Hemming, a reporter and newspaper editor, reasoned in his book about Fitzgerald that the USCG's conclusions "were benign in placing blame on [n]either the company or the captain ... [and] saved the Oglebay Norton from very expensive lawsuits by the families of the lost crew

Cheers


H.

BandB said:

If you don't see fault with the company, then you haven't read the report. Read it and get back to us on that statement. They even used the word of the vessel operating autonomously, basically saying they had no one watching or tracking the vessel or the storm and felt no obligation to do so.

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I read the report, at least most of it. I hold that fault lies squarely on the shoulders of the master. Company could be quibbled over about whether they did or did not do this or that, granted. But the master was sleeping in his cabin as the old ship charged at 20kts into a difficult to predict storm.

Interesting how so often when we're discussing commercial shipping disasters (as opposed to recreational incidents) it divides into the company bashers and those whose place the responsibility on the captain. I've never worked commercial shipping but when these debates break out, I usually have the same thought -- a captain is charged with life and death responsibility, in real time, on the scene, and makes multiple decisions sometimes minute by minute on the operation of a vessel and the safety of the crew. Awesome responsibility -- and yet that same widdle captain gets all intimidated and pressured and caves-in to the big bad corporation and against his better judgment sails himself and his crew into potentially fatal situations because he can't assert himself? Yeah yeah, I know, he has a mortgage to pay, etc. Almost all of us need our jobs at least for some period of time, that doesn't mean I'd risk my life or the lives of my employees because of "corporate pressure." I may lose my house in foreclosure if the shipping company fires me for being cautious but that 5,000 square foot house does me no good either if I'm fish food on the bottom of the ocean.

kthoennes said:

Interesting how so often when we're discussing commercial shipping disasters (as opposed to recreational incidents) it divides into the company bashers and those whose place the responsibility on the captain. I've never worked commercial shipping but when these debates break out, I usually have the same thought -- a captain is charged with life and death responsibility, in real time, on the scene, and makes multiple decisions sometimes minute by minute on the operation of a vessel and the safety of the crew. Awesome responsibility -- and yet that same widdle captain gets all intimidated and pressured and caves-in to the big bad corporation and against his better judgment sails himself and his crew into potentially fatal situations because he can't assert himself? Yeah yeah, I know, he has a mortgage to pay, etc. Almost all of us need our jobs at least for some period of time, that doesn't mean I'd risk my life or the lives of my employees because of "corporate pressure." I may lose my house in foreclosure if the shipping company fires me for being cautious but that 5,000 square foot house does me no good either if I'm fish food on the bottom of the ocean.

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It's easy to say "I would have" when you've never been there....

Also very judgemental to assume he was making all this money and some 5000 sqft house.

BandB said:

I don't believe they outright said that

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I do. I have been involved in conversations that went EXACTLY like that.

Whether or not the company said a sissy boo or had lightning bolts shoot from the heavens....threatening job security.......hmmmmmm...

I have been asked more times than I can remember to do something risky, involving my death, and maybe others too.

Through helo missions or towing or salvage jobs......the question would come up and I would get a queasy feeling.

I was fortunate that saying no probably never would have cost me my job, so many times I just said no. But many times I said yes even though the odds weren't so strong that I could guarantee anybody anything.

Saying no is a tricky thing.....someone is thought to be really good because they have mastered the odds, till they dont......then they are a bum for not fullfiling their responsibility.

I feel that I was prerty good at things I did, but in all fairness, I was lucky too. Out of all those times that I risked it......a bigger wave, a stronger gust of wind, an engine cough, etc...etc were all that stood between me and catastophe.

So yes, I say thanks to those who watch over me .....for me, but in the long run the thanks is for allowing everyone all those years that were counting on me to come home safe too.

Responsibility is a moving target....I am not sure anyone that makes a decision that ultimately can kill someone else ever can work hard enough to be perfect.

kthoennes said:

Interesting how so often when we're discussing commercial shipping disasters (as opposed to recreational incidents) it divides into the company bashers and those whose place the responsibility on the captain. I've never worked commercial shipping but when these debates break out, I usually have the same thought -- a captain is charged with life and death responsibility, in real time, on the scene, and makes multiple decisions sometimes minute by minute on the operation of a vessel and the safety of the crew. Awesome responsibility -- and yet that same widdle captain gets all intimidated and pressured and caves-in to the big bad corporation and against his better judgment sails himself and his crew into potentially fatal situations because he can't assert himself? Yeah yeah, I know, he has a mortgage to pay, etc. Almost all of us need our jobs at least for some period of time, that doesn't mean I'd risk my life or the lives of my employees because of "corporate pressure." I may lose my house in foreclosure if the shipping company fires me for being cautious but that 5,000 square foot house does me no good either if I'm fish food on the bottom of the ocean.

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Well, I'm an equal opportunity basher. I think the Captain absolutely should be held accountable and you don't risk the lives of others for any amount of money as difficult as that may be. Fear of loss of job just isn't a reason. We'll never know what thoughts led to the captain's decisions or how much he was influenced by various factors. His acts were clearly wrong.

I also bash the companies that allow their employees to put themselves in harms ways and, in some cases, even encourage it through their history of actions and responses.

It's an ugly environment and culture many companies create and unfortunately a few captains sell their souls to the company without even realizing it. Everyone working on this vessel for TOTE was scared of not having a job when it was moved to Alaska. The captain was and the crew was scared of the captain which is common to pass the fear and stress on down the line.

The goal obviously is to prevent such events from happening again. Fines and new rules may help. However, they don't send nearly the message that criminal charges do.

Good companies have hotlines or whistleblower numbers which lead outside the company and on which the employee's identity is protected.

SaltyDawg86 said:

I do. I have been involved in conversations that went EXACTLY like that.

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I don't doubt that you have. However, in this case they weren't even paying attention. The pressure came from worry over a job in Alaska and they didn't need to say anything to stress that. They had everyone in a waiting position. Cause problems and you wouldn't likely get a job in Alaska.

The captain should have been more on top of things and so I agree that his actions were criminal.

Regarding the company, it is more than just the implied pressure at the time of sailing. It is the history of the company and the culture it creates. I believe this captain was disciplined before for altering a route around bad weather and it cost a few days sailing time. He was also being considered for a promotion and I'm sure that impacted his decision. In many non maritime lawsuits if the culture can be proven to be an underlying factor, the company is found liable. This is usually in a civil suit however, rather than a criminal suit. In a sexual harrassment suit for instance the court considers not just the overt act of some misogynist, but also the fact that there may be posters of girls on the working floor, or the workers to to a strip club every Friday, and so on. Culture is very hard to define so it can be difficult to be held accountable when it is a negative factor on employee well being.

There is also the maintenance of the ship that the company is responsible for. Do they just do what is needed to pass inspections, and only when forced into it, or do they back up their safety officers and stay on top of things that need fixing before inspections are failed. Didn't things start to go bad because the engine failed ? And I thought some hatch covers were missing latches or something along those lines.

Unless it costs TOTE a significant money it will continue to be more profitable for them to keep doing business as usual.

I lost 2 jobs and a lot of money when I refuse to drive a truck in unsafe condition I did not hesitate. The problem I see is the info provided to that captain. The direction of the storm had 2 models US and European. The US model shows that the storm will not be on the way, but EU shows correct track. I have been tracking a hurricanes for some time ( I live in Florida) and look to me that the EU model shows correct path. I believe that captain decision was base on hurricane tracking model that was wrong at that time.

You can't put much faith in hurricane predictions. Turns out the EU model was better, but it could have been wrong also. The storm was doing strange motions, not the typical curves we are so used to seeing. A prudent master would give it wide berth, he did not.

An old ship has unknown weaknesses. Suspected corroded ventilation ducts and other hidden weaknesses shipped water in conditions it normally did not venture into. Run an old ship like that and best to avoid storms.

Well I've gotten some good laughs, but I'm going to go ahead and bow out this thread before I say some unpopular things.

In general, I try to avoid making comments about subjects I am not familiar with. Having been away from commercial tankers for 30 years, I don't know first hand what type of pressures they are under.

I will say there is a big difference between a 750 ft ship getting to port in time, as opposed to a truck, or a smaller boat and the economics involved at the corporate office.

From what I have read over the years and talking to ex class mates who still sail, the cargo and tanker crews do get this pressure, and Salt who is an unlimited tonnage officer backs that up. Yes, it is his opinion, but also the world he lives in.

The Gulf rig blowout, explosion, and major spill involved a scenario of events in which corporate put pressure on the local rig operators to continue drilling even though there were many red flags leading up to the blowout preventer failure. If you have not read it, Fire on the Horizon, by the G Captain website creator is worth reading.

Fletcher500 wrote, "If you have not read it, Fire on the Horizon, by the G Captain website creator is worth reading."

Second that recommendation.

A few observations:

Until I read the complete transcript from the El Faro's bridge voice recorder, I was inclined to defend the captain. He had inadequate weather data, the storm behaved unpredictably, etc., etc. But reading his words in context allowed me to better see that he was behaving with a certain arrogance that, in the event, turned out to be reckless. Accusations of the captain's negligence are justified, I am sorry to say.

I have worked as a skipper for a maritime corporation, and have owned commercial vessels for which I hired and supervised licensed captains. In both positions, everyone understood that the job meant running trips efficiently and on-time. Fail to do that once or twice, and the heat comes on. Miss your schedule any more than that, and an owner has to consider whether it's time to make a change. Everyone gets that. But - and this is a big but - a boat doesn't do its owner any good if it's damaged or sunk, and dead or injured passengers or crew are a major-league headache. IOW, when I sent a captain out with my boat, yeah, I wanted them back on time, but above all, I wanted them back. Same with my employers, who trusted me with total responsibility for their multi-million dollar capital investments, and all the souls on board.

Maybe TOTE's corporate culture lacked enough checks and balances, but I'm not confident that we can see clearly into the hearts of people. Corporations are not people [the U.S. Supreme Court in Northwestern Nat Life Ins. Co. v. Riggs (203 U.S. 243 (1906)) notwithstanding], so they have only as much conscience and integrity as the people who run them. I think that the people of TOTE, and the El Faro's skipper, were more surprised and crushed by what happened than anyone, other than the crew's loved ones.

Finally, I'll reiterate what I've posted here before on the subject of hurricane predictions. As a direct result of the El Faro, the NTSB issued a public safety alert, here: https://www.ntsb.gov/safety/safety-alerts/Documents/SA-065.pdf reminding mariners where to go for the best data on tropical storm forecasts. Bottom line: if a developing or approaching tropical weather system affects your interests, pay close attention to the NWS's “Tropical Cyclone Discussion" page. It is unavailable anywhere else. It's what the name says it is, a recital of the facts and assumptions in play as forecasters practice their art. Each named or numbered tropical system has its own discussion page. It always makes for interesting, and sometimes vital reading.

I second the comment about reading the transcript. I read it too and agree that it can explain some of the context of what happened. From my reading, it seemed to me that the Captain mis-read the hurricane's direction and intensity because of where he was getting his information.

If you're really interested in what happened, I strongly recommend that you read the transcript and start at the beginning. Google it online.

Questions for experts:

If, after the ship lost power but the generators were still running, would fully lowering both bow anchors and blocking the rudder amidships keep the bow pointed into the waves?

Would stern-way speed be acceptable?