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GMiller

NTSB releases transcript of El Faro sinking

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It's hard to resist becoming the Trinity Brethren* here, and I include me in this tendency, which is tempting to do from a keyboard on shore.

 

There really is a "fog of war" when things really horribly bad, and it's the actors themselves who are probably in the worst position to see through it. Much easier for us, in quiet surroundings.

 

 

There wasn't much "fog of war" on board El Faro at 11am on sept 30.., when they received the weather forecast i have copied below. Conditions were quite good then.

 

this is about 45 hours before the ship sank at 7:40am on Oct 1

 

That forecast image is from the meteorological factual report - it is a screenshot from the BVS program that was used aboard the ship. The forecast loaded is known from email logs to have been delivered to the ship at 11am sept 30. At this time the ship had just finished crossing the Straits of Florida.., and was somewhere just north of the northwestern-most Bahama Island.

 

We know that the captain had a computer in his office that could view these forecasts.., and that there was also one on the bridge.

 

This what they were actually looking at on the ship...

 

While this forecast was sent to them at 11am on the 30th.., the valid time displayed is for 8am on the 1st - about 20 minutes after the ship sank

 

GFS wind is displayed with barbs.., significant wave height from WW3 is contoured and colored

 

The program is also displaying the NHC forecast location of the storm for the 8am oct 1, and the wind speed quadrants, also from NHC

 

the first thing anyone would notice is that the storm symbol is a filled hurricane symbol - so the storm was already forecast to reach hurricane strength (not tropical storm strength) when they would pass near it 45 hrs later.

 

the wind speed circles/quadrants from NHC are for sustained winds of 64kts or greater, 64-50, and 50-34 kts respectively, moving out from the center. Note that while the GFS winds in the outer bands more or less agree with the NHC human forecast shown by the rings.., it doesn't do a good job near the center - as i mentioned above, global models (among other issues) do not have the resolution needed to predict the very high winds that occur in the center of a hurricane.

 

I have a hard time imagining that anyone would look at a decision to keep steaming SE, when faced with that forecast, and say it was anything other than a bad decision.

 

yes, at this point they would have had to backtrack a bit to get back to the straits of florida and take the easy route to the Old Bahama Channel.., and perhaps the captain though that backtracking would have been seen by the crew as evidence that he had made a mistake.., and he didn't want to deal with that...

 

post-290-0-92668100-1481913116_thumb.png

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Agree - this was no different than the Bounty, went full steam into a widely predicted disaster :(

Yes, several similarities to the Bounty.

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Bingo Nolatom! The armchair sailors can Micro manage this all day long and it amounts to nothing. El Faro sank because of a cascade of events that started with a scuttle hatch coming undone. Flooding causes list, list causes lube oil pumps to loose suction (which shuts down the steam turbines), no steerage leads to increased roll and list which causes cargo to break free rupturing a fire main which increases flooding until it is unrecoverable.

To compare this Captain to the one on the Bounty is a disservice to the El Faro's Master.

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Bingo Nolatom! The armchair sailors can Micro manage this all day long and it amounts to nothing. El Faro sank because of a cascade of events that started with a scuttle hatch coming undone. Flooding causes list, list causes lube oil pumps to loose suction (which shuts down the steam turbines), no steerage leads to increased roll and list which causes cargo to break free rupturing a fire main which increases flooding until it is unrecoverable.

To compare this Captain to the one on the Bounty is a disservice to the El Faro's Master.

 

so.., with the forecast i posted above.., you would have said "keep going"?

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I think he's arguing that the spiral of disaster started with the scuttle. Not the ignored weather forecast.

Bingo! Wishing they had better info doesn't do anything.

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I think he's arguing that the spiral of disaster started with the scuttle. Not the ignored weather forecast.

 

fine - he can argue that...

 

I will argue that if you make a series of decisions that put your ship with in a few miles of the eye of a cat 4 hurricane.., the "spiral of disaster" starts with those decisions...

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I think he's arguing that the spiral of disaster started with the scuttle. Not the ignored weather forecast.

Bingo! Wishing they had better info doesn't do anything.

 

 

they didn't need better info!

 

the info i showed was the info they had.., and the info they had got worse from there!

 

the initial problem was a failure of the person in command to respond to the weather forecast that he had.

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It's hard to resist becoming the Trinity Brethren* here, and I include me in this tendency, which is tempting to do from a keyboard on shore.

 

There really is a "fog of war" when things really horribly bad, and it's the actors themselves who are probably in the worst position to see through it. Much easier for us, in quiet surroundings.

 

 

There wasn't much "fog of war" on board El Faro at 11am on sept 30.., when they received the weather forecast i have copied below. Conditions were quite good then.

 

this is about 45 hours before the ship sank at 7:40am on Oct 1

 

 

I didn't realize that September had 31 days... actually only 8:30 before the ship sank.

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It's hard to resist becoming the Trinity Brethren* here, and I include me in this tendency, which is tempting to do from a keyboard on shore.

 

There really is a "fog of war" when things really horribly bad, and it's the actors themselves who are probably in the worst position to see through it. Much easier for us, in quiet surroundings.

 

 

There wasn't much "fog of war" on board El Faro at 11am on sept 30.., when they received the weather forecast i have copied below. Conditions were quite good then.

 

this is about 45 hours before the ship sank at 7:40am on Oct 1

 

 

I didn't realize that September had 31 days... actually only 8:30 before the ship sank.

 

 

whoops - you are right!

 

still, i don't think that makes a difference to my point - the forecast that they were looking at at that time for where they would be the following morning was bad enough that they should not have continued on.

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I'm curious what corporate reaction occurs when a skipper refuses to sail, reroutes his ship or otherwise alters a schedule for reasons of safety. He has the legal,responsibility, undeniably, Nolatom's link to the 1983 loss showed ship owners being stupid for minimal cost savings, with two captains, union crew, surveyors and the USCG failing to question their decisions. Grain was moisture damaged from rusted out patchwork hatches sealed by tar and roofing felt, Til the ship was lost. What pressure does a modern skipper face? El Faro's master felt the need to ask the owner's approval, and maintained his course when he failed to get it, Unless the ship founders, how do you know if the captain was right or wrong?

 

With the wealth of data available in a modern investigation there is always plenty of blame to spread around. Did a mate Inadequately secure cargo as the captain and cm discussed before the storm? why did the captain fail to stay on top of weather? Did the bridge crew not receive proper training on the electronics? Were the owners too miserly with bandwidth? Was the captain overconfident? The engineer seemed to have the respect of the crew, but failed to know the danger his engines were in due to heel. Somebody or several somebodies failed to secure the skuttle. The crew failed to recognize the second leak, possibly hindered by inadequate instrumentation. Was the second leak related to moving cargo, or old pipes rupturing as the ship worked? Nobody realized the danger of sudden capsize, the danger of the storm was obvious. If somebody did a minute by minute on the last 24 hours for any of us forced to manage and make important decisions, several failings would no doubt be evident. We get to ignore our failings when there is no consequence, and blame others when there is. But sometimes there is no second chance.

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whoops - you are right!

 

still, i don't think that makes a difference to my point - the forecast that they were looking at at that time for where they would be the following morning was bad enough that they should not have continued on.

 

 

I couldn't agree more. The six hours the Captain was down in his cabin while things went completely pear shaped was also a big factor in the tragedy. Bottom line is they should have done the prudent thing and diverted or even turned back. A 40 year old Ro-Ro is not really a ship you want to go into those conditions. It's a chilling read and the CAPT's final words are haunting.

 

-Snap

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So they were just cruising along, no issues, and a nasty old hatch did them in. Hurricane had NOTHING to do with it :rolleyes:

 

Bingo Nolatom! The armchair sailors can Micro manage this all day long and it amounts to nothing. El Faro sank because of a cascade of events that started with a scuttle hatch coming undone. Flooding causes list, list causes lube oil pumps to loose suction (which shuts down the steam turbines), no steerage leads to increased roll and list which causes cargo to break free rupturing a fire main which increases flooding until it is unrecoverable.
To compare this Captain to the one on the Bounty is a disservice to the El Faro's Master.

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Its tough when people die on the job. Should never happen. Frankly its difficult for me to view the demise of the El Faro as anything other than negligent behavior on the part of the captain. Regardless of how his decision making malfunctioned, when someone in that position lets their ego or disenchantment with their employers or whatever cloud their objectivity, its time to hang up the spurs. Maybe the job gets so mundane that good sense just falls asleep but that job is about being vigilant and on the ball. It was his job to be smarter than all of us in that place and time as he had the most to lose. He chose not to be for whatever reason. He took people with him. He failed at his task. People dont get a pass for their actions because their actions killed them. Its sad and horrific to read this but it makes me angry and I am sure the relatives of the crew are far angrier than I.

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It's hard to resist becoming the Trinity Brethren* here, and I include me in this tendency, which is tempting to do from a keyboard on shore.

 

There really is a "fog of war" when things really horribly bad, and it's the actors themselves who are probably in the worst position to see through it. Much easier for us, in quiet surroundings.

 

 

There wasn't much "fog of war" on board El Faro at 11am on sept 30.., when they received the weather forecast i have copied below. Conditions were quite good then.

 

this is about 45 hours before the ship sank at 7:40am on Oct 1

 

That forecast image is from the meteorological factual report - it is a screenshot from the BVS program that was used aboard the ship. The forecast loaded is known from email logs to have been delivered to the ship at 11am sept 30. At this time the ship had just finished crossing the Straits of Florida.., and was somewhere just north of the northwestern-most Bahama Island.

 

We know that the captain had a computer in his office that could view these forecasts.., and that there was also one on the bridge.

 

This what they were actually looking at on the ship...

 

While this forecast was sent to them at 11am on the 30th.., the valid time displayed is for 8am on the 1st - about 20 minutes after the ship sank

 

GFS wind is displayed with barbs.., significant wave height from WW3 is contoured and colored

 

The program is also displaying the NHC forecast location of the storm for the 8am oct 1, and the wind speed quadrants, also from NHC

 

the first thing anyone would notice is that the storm symbol is a filled hurricane symbol - so the storm was already forecast to reach hurricane strength (not tropical storm strength) when they would pass near it 45 hrs later.

 

the wind speed circles/quadrants from NHC are for sustained winds of 64kts or greater, 64-50, and 50-34 kts respectively, moving out from the center. Note that while the GFS winds in the outer bands more or less agree with the NHC human forecast shown by the rings.., it doesn't do a good job near the center - as i mentioned above, global models (among other issues) do not have the resolution needed to predict the very high winds that occur in the center of a hurricane.

 

I have a hard time imagining that anyone would look at a decision to keep steaming SE, when faced with that forecast, and say it was anything other than a bad decision.

 

yes, at this point they would have had to backtrack a bit to get back to the straits of florida and take the easy route to the Old Bahama Channel.., and perhaps the captain though that backtracking would have been seen by the crew as evidence that he had made a mistake.., and he didn't want to deal with that...

 

attachicon.gif1100EDT 9-30.PNG

 

 

 

i was looking at the transcript again..,

 

and at about 11am the sat-c gets a message - probably a wx forecast.., this is about the same time as the forecast in the screen shot is sent to the BVS software over the FBB - although as i mentioned somewhere above these may not have been the same forecast because the BVS forecasts were essentially one forecast behind some of the time. but the captain and the 3m discuss it and seem to say they are about the same

 

the captain states his plan to "duck underneath it".., and within a few minutes he appears to leave the bridge

 

the remaining crew discuss the forecast of "gusts to one-twenty"

 

at about 11:45 the 2nd mate comes on the bridge - i think her watch starts at 12:00

 

at 11:47 she mentions that the captain is down below downplaying the storm to the crew - it's clear that she doesn't agree with him

 

at 11:50 she repeats that comment, and then says: "think he's just tryin' to play it down because he realizes we shouldn't have come this way. * saving face ***."

 

which is basically what i suggested in my post above...

 

i think once he had crossed the straits of florida.., he figured he had lost his chance to take the old bahama channel, and that going back would be admitting a mistake in front of the crew, which he didn't want to do..

 

There are interviews with both the mom of the 2nd mate and friends of the 2nd mate - she didn't have a very favorable opinion of this captain

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He was fired from a previous job for standing up to management over a safety issue. Once bitten twice shy.......

 

BTW - The Bounty had *made it past the hurricane*. They had nothing but improving weather ahead of them. Several issues with poor maintenance of their pumps and generators plus a crap job of caulking did them in. No leaks - no problems. Good pumps - no problems. You could say sailing in hurricanes was fine for them too if only they could pump the bilge :rolleyes:

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I do not believe any rational evaluation of causation would include the weather as more than a minor contributing effect. Remember, the ruptured fire pipe alone could easily have caused the vessel to founder in otherwise calm conditions.

 

To say the weather was the cause, while comforting to many, takes one down a path in which the cause could just as easily be "having left the dock" or "having chosen a maritime career". Both are true, but neither produces remedial actions that are helpful for preventing similar outcomes in the future.

 

The causation here is likely among, in order:

  1. Lack of sufficient watch keeping to have detected the flooding in time to take remedial action
  2. Inadequate bilge water level alarms (or lack of maintenance of alarms) that prevented understanding of flooding
  3. Failure to adequate secure cargo, which subsequently came loose and may have led to the scuttle and/or fire pipe damage
  4. Down flooding through the scuttle
  5. Ingress of water through the firefighting system

The only remedial actions I can imagine are to mandate some linkage between the angles of heel at which the plant can operate and the angle of vanishing stability for the hull form at various loadings. It's just silly to me that these would be completely independent concepts - provided it's not flooded, the plant should run until the thing rolls over.

 

I would be surprised if any forecasting or communications comes up as more than advisory - commercial shipping often looses communications. There's a basic assumption that the ship can get from point A to point B without anything other than good maintenance, good charts & good watch keeping - everything else is optional. I doubt that's ever going to change.

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I would be surprised if any forecasting or communications comes up as more than advisory -

 

well - i agree with that part...

 

they had all the weather info they needed - the captain just ignored it!

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I do not believe any rational evaluation of causation would include the weather as more than a minor contributing effect.

 

 

really?

 

Does this change your mind at all?

 

Joaquin_2015-10-01_1145z.png

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Moonduster on steam turbine ships the lube oil system is for main turbine bearings. As a safety that lube oil pressure keeps the main steam throttle valve open. Loss of oil pressure closes that valve and stops the turbine to prevent bearing loss.

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Moonduster on steam turbine ships the lube oil system is for main turbine bearings. As a safety that lube oil pressure keeps the main steam throttle valve open. Loss of oil pressure closes that valve and stops the turbine to prevent bearing loss.

That is my understanding. I'm not greatly familiar with steam turbines, though. I assume the engine has a dry sump, since the main shaft is in the middle of the block. I also assume the bearings are roller or ball bearings, with seals on either side? Although operating the engine at an angle of heel would be an unusual, even extreme, circumstance; I think the dry sump design it appears to be should allow for adequate lubrication. Isn't there multiple pickups in the lube oil tank for the pump to pick up? Perhaps someone here can chime in with answers.

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Steam turbines spin really fast. The bearings are journal bearings. A complicated seal and evacuation system keeps the oil and steam confined (and generally separate).

 

Big grey boats are designed to keep going with lots of heel / list. I don't know what the limitation would be on a commercial ship.

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You're missing the point entirely. Why design a lube oil mechanism that fails at an angle of heel that is substantially less than the safe operating heel of the vessel. That's a lousy design trade off.

 

And no, I'd seen the location of the ship relative to the eye. But that storm was survivable had the boat not flooded. And had it flooded beyond its stability limits in flat calm water, it would have sunk then, too. This had nothing to do with weather and everything to do with flooding. The focus should be on why the flooding was undetected and that's about watch keeping.

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From some online reading I did, it sounds like most of the big turbines use babbitt bearings. There's multiple oil pumps, including at least 2 backups, one A/C generator driven and one battery powered. Need to keep oil pressure up after plant shuts down while it coasts down. There's also much redundancy in oil lines, and temp gauges for each bearing, so one single oil line failure doesn't take out a bearing. With that kind of redundancy, most likely there's more than one oil pickup in the main lube oil tank. Now I'm really befuddled... it doesn't appear that 15 deg of list should have caused loss of oil pressure. Maybe there's domething more than just that.

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You're missing the point entirely. Why design a lube oil mechanism that fails at an angle of heel that is substantially less than the safe operating heel of the vessel. That's a lousy design trade off.

 

And no, I'd seen the location of the ship relative to the eye. But that storm was survivable had the boat not flooded. And had it flooded beyond its stability limits in flat calm water, it would have sunk then, too. This had nothing to do with weather and everything to do with flooding. The focus should be on why the flooding was undetected and that's about watch keeping.

 

well, it was a cat 4 at that point.., so...

 

but yes.., i do agree that there is a problem with the detection of flooding and the response. i looked online at pictures of scuttles, and i wonder if they are really big enough to have caused much of the problem - if i understand correctly, they are up on deck and would have only taken water when waves washed over the deck. i don't have much of a sense of how much water the fire main could pump into the boat, but i also wonder if that was enough to cause the list - maybe together...

 

another point that i would make is this: you basically are arguing that if the boat hadn't had a series of problems.., it would have been fine in the storm - but everyone knows that things go wrong, and stuff breaks in big storms! that's one of the reasons to avoid them..

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You're missing the point entirely. Why design a lube oil mechanism that fails at an angle of heel that is substantially less than the safe operating heel of the vessel. That's a lousy design trade off.

 

And no, I'd seen the location of the ship relative to the eye. But that storm was survivable had the boat not flooded. And had it flooded beyond its stability limits in flat calm water, it would have sunk then, too. This had nothing to do with weather and everything to do with flooding. The focus should be on why the flooding was undetected and that's about watch keeping.

well, it was a cat 4 at that point.., so...

 

but yes.., i do agree that there is a problem with the detection of flooding and the response. i looked online at pictures of scuttles, and i wonder if they are really big enough to have caused much of the problem - if i understand correctly, they are up on deck and would have only taken water when waves washed over the deck. i don't have much of a sense of much water the fire main could pump into the boat, but i also wonder if that was enough to cause the list - maybe together...

Given the est wave heights, 20-30', it's pretty likely there was a lot of water on deck. The scuttle dogs should have been plenty strong enough to hold it closed. If open, yea it would admit a fair amount of water. As I understand, the firemain is continuously pressurized. It also feeds the heads, cooling condensers, etc. It would also admit a fair amount of water, but I would think there's pressure and flow gauges that would alert to a breakage. I'm not sure why the crew was so confused about the source of the ingress, unless there was a third possible source like hull breach. That might also explain why they couldn't pump the hold out even after closing the scuttle and shutting off the firemain.

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Ruptured fire line causing a list is bshit any line in the system can be isolated.

Also they run dry sump lubrication so losing suction do to list isn't plausible.

This ship sounded like a heap of shit combined with a really really bad decision to sail into a cat 3/4 hurricane equals disaster

Bad things can happen an a calm day given but the chances of over coming said thing are much higher on a calm day than in a hurricane.

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15 degree list??? Well, in a hurricane such as this, that might be the average but the ship would likely be rolling as much as 30-45 degrees from vertical either way, except minus the list so say 45 degrees one way, 15 degrees the other way. A ruptured fire main would take hours to add a significant flooding component but probably didn't happen until flooding from the scuttle or elsewhere, got things moving around in the hold. Water rushing back and forth in a hold would pretty quickly destroy cargo lashings and bracing no matter how well secured. With the constant list, I'd be more inclined to believe it was from shifted cargo.

 

I haven't seen or heard whether there was any evidence of hull breech but I'd bet strongly on it as the coup-de-grace. (did I miss anything on that?)

 

And yes, the storm played a significant role in the vessel's demise, some comments not withstanding. A 15 degree list in flat water wouldn't have done anything. However, in flat water a 15 degree list caused by water/free surface effect would have been noticed long before it was 5 degrees and then dealt with.

 

I'm not going to read all 500+ pages but it seems like the Captain was overly dependent on 'approval' to make any major decisions regarding routing. Things may have changed but 25 years ago, I would only have 'advised' the office of my actions, not asked for instructions nor awaited approval. I couldn't live with having that limited of a decision capability. If true, then the shipping company killed the crew.... That's why you hire a Captain, so he can make decisions 'on scene' and not 'ask permission' from a desk driver. With a ship of that age, I don't think I'd have even gone close to that route but that's with 20/20 hindsight I suppose.

 

(Anecdotally, I remember the office (on my first command) telling me that they'd 'manage' my fuel burn rate while crossing the N Pacific in early winter. I laughed and ignored them and did my own 'managing' in consultation with the Ch Engineer....and no, they didn't have some fuel management software that gave them anymore info than I had. It wasn't their job nor responsibility, it was mine. Period. If I ran out, I'd have been the one defending my decision/license...)

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I'm not going to read all 500+ pages but it seems like the Captain was overly dependent on 'approval' to make any major decisions regarding routing.

 

might be true.., but i didn't see anything in the transcript that supported this position

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That last discussion with the QI (office duty person- "Qualified Individual") bothers me a bit but I may be reading into it... There's a fine line between notifying the office and then having them 'try to help' by telling you what you 'should/could' do. But it's true, they DO like to know what's going on so I'll give a little grace on that call.

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Comments on the transcript by the 2M (while captain was in his cabin) indicate she thought the captain was pushing ahead out of pride, not wanting to admit a mistake by turning back. They may have just been covering their ass, but TOTE's statement following the sinking was that the captain had the authority to pick his route, and wasn't governed by a strict schedule.

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Comments on the transcript by the 2M (while captain was in his cabin) indicate she thought the captain was pushing ahead out of pride, not wanting to admit a mistake by turning back. They may have just been covering their ass, but TOTE's statement following the sinking was that the captain had the authority to pick his route, and wasn't governed by a strict schedule.

This is as it is supposed to be-'-up to the captain'. There are lots of unwritten and unspoken pressures on a Captain, but in the end he carries the burden of making the best decision he can. Sometimes it proves to have been the wrong one(s). We all pray that our mistakes don't cost life or limb.....

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http://www.pressherald.com/2016/05/17/captain-of-similar-vessel-says-el-faro-owner-fired-him-for-airing-safety-concerns/

Possibly fired because drugs were hidden on the ship. Are all captains fired if a crew is caught smuggling? Or only if they perceive the skipper as too cautious to maximize profits,

 

http://gcaptain.com/el-faro-captain-fired-crowely-row-safety/

 

http://jacksonville.com/news/metro/2015-10-05/story/who-michael-davidson-captain-missing-el-faro

"Nice, smiling, but also arrogant, He was cautious maybe, but also,submissive to the demands of the company, The ship was in bad condition, they (unlicensed sailors who had recently sailed on the El Faro) said but tote has announced it was readying new ships that would run on liquified natural gas. Not everyone on the crew would be needed for the new ships." The crew called the hull strong but worried about things that could break on the black box recordings, contradicting part of this story,

 

Most large failures appear to be a cascade of bad events and decisions, the reason they are so rare. I'm hesitant to judge those on the scene too harshly, especially as he died well doing what he could to atone for the earlier choices. I'm more interested in any role corporate culture may have played in the tragedy, since that will affect other ships.

 

http://www.cbsnews.com/news/60-minutes-el-faro-lost-in-the-bermuda-triangle/ Looks like the owners said they gave no guidance on avoiding the storm. The bridge conversation seems to contradict this.

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http://www.cbsnews.com/news/60-minutes-el-faro-lost-in-the-bermuda-triangle/ Looks like the owners said they gave no guidance on avoiding the storm. The bridge conversation seems to contradict this.

 

where in the transcript?

 

 

 

I didn't see any evidence in the transcript but could have missed it. (apart from the one sided responses to what seems like a number of questions from the QI on that last call. Mostly, I think those questions were pretty irrelevant given the circumstances. I mean, I don't think it was like they raised issues that the captain hadn't already thought about..... However, the QI was mostly getting responses so HE could tell his boss what was going on.)

 

Owners are pretty good about not overtly crossing the line. It's the corporate culture and innuendo and how they say something rather than what they say that either puts the pressure on a captain or not. We certainly can't uncover that aspect from what little info we have and even a court would have a hard time absolutely quantifying whether the owners put undue pressure on a captain.

 

It IS safe to say that most responsible ship captains put enough operational pressure on themselves anyway that additional owner pressure (real or imagined) is not going to make the difference in most cases.

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CAPT

14:05:33.9 14:05:36.8. I hope (we get to / that it doesn't) take the Old Bahama Channel back. * *.

 

2M: does the company (want/give) permission now (or) * *.

 

Capt: (from) management.

 

2M: cause it used to be just we're doin' it. you people are sittin' in your office behind a desk and we're out here we're doin' it. * yeah.

 

Capt: well I'm extending that professional courtesy because it does add a hundred and sixty nautical miles to the (distance).

 

2M: yeah but it also sav saves on the ship's stress stress of the ship.

 

Capt: that's why you know I just said hey you know I would like to take this goin' northbound. I'll wait for your reply. I don't think they'll say no. I gave them a good reason why because if you should follow this (down) then look what it does on the third fourth and fifth. and that's right where we're going. on the quarter. [during the time the CAPT was speaking, the 2M interjects, "yeah" and a "yeah I saw that."]

 

2M: uh huh.

**all (lightly) loaded in that case (it) gets even worse.

 

Capt: so I just put it out there (see what happens).

 

 

 

 

And a few hours later:

CM 18:59:54.0 18:59:59.5 I hear what you're saying captain. I'm in line for the choppin' block...

CAPT 18:59:59.1 19:00:00.6 yeah. same here.

CM 19:00:00.0 19:00:01.8 ... I'm waitin' to get screwed.

CAPT 19:00:01.6 19:00:02.6 same here. CM 19:00:03.4 19:00:05.5 I don't know what's gunna happen to me.

 

section of lost recording, followed by a discussion of contracts.

 

and

 

CAPT 19:10:38.0 19:10:49.8 my recommendation is simpler simpler than uhh explaining to an

unseasoned (pending weather) * *

 

 

These two conversations and lack of course change suggest to me he asked for permission, was concerned about his job and didn't get the owner's blessing. Nobody bad mouths the employer on the recording or anything obvious like that. Rereading it now, It may be he wanted the Bahama channel for the return trip? Is there a reason he would have requested that?

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i think that section at 18:59 is more a general concern about the future, than a specific concern related to changing the route on this trip - boats ( including el faro) were being repositioned, they were getting new boats, and no one was sure what job they would have when the dust settled.

 

still, i agree - he is showing that he did care about what t he office would think if he changed the route

 

and it is certainly possible that the general concern about the future, affected his thinking about changing the route on this voyage

 

i forgot about that part

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Fuck Cappy Davidson and all of his ilk!!! I have seen too many of these "macho" assholes lying by the side of the rode with their "this is nothing compared to Alaska" dick in their hands. Total respect to the ship masters that deliver day in and day out. Boring, but safe. You want to be a hero, do it on your own fucking dime. I have sailed with one of these assholes before and vowed "never again!" The quiet master, always at the bridge, never without his coffee- that is the guy I totally respect. Never raises his voice and the crew never hesitates. Respect.

 

My apologies if I offended anybody...

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I got caught by a hurricane once way back in the day before hot and cold running datlinks, but given modern weather forecasting I have been amazed to watch *2 different ships* go straight into a totally obvious hurricane and sink :unsure::o

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Kent,

 

Mid-90s they evacuated the Port of Norfolk and Hampton Roads based on projected land fall of a Cat 1/2. The hurricane actually turned out to sea before making landfall so we had a great ride!

 

Port Whiner,

 

So you have sailed with those "types" before? I've sailed with your type too. Those that say nothing and contribute less while on board but back on shore they have all the answers and tremendous opinions of how the ship would not sail without them aboard. Second guessing back benchers like yourself are a dime a dozen and I've got no change.

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Some of you are gCaptain readers. This is a (very) long and occasionally rambling criticism/suggestion box from its editor for investigating marine casualties, threads that should be followed up on in this investigation, why don't we learn (consistently) from past investigations.

 

May be of interest. It was to me, who in a former life was a Coast Guard inspector and marine casualty investigator.

 

https://gcaptain.com/el-faro-top-10-failures-ntsb-investigation-glive-e21/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+Gcaptain+%28gCaptain.com%29

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Unknown, if by my "whining" I make someone think- "You know, this might be a bad idea" when circumstances appear to indeed support that conclusion, then I am OK. Stupidity and Nobility are different.

 

I read the transcript and thought "why is the capitan going on about how bad Alaska is when he is in the Caribbean?" Were he sailing in Alaska, cargo would have been properly secured and the ship prepared for expected weather conditions. Captain knew the ship was not thusly prepared. This is abundantly clear in the transcript.

 

I feel no need to recite my seagoing experience, but I will say that my advice was taken some times, and other times it was not. I have over-reacted some times, and other times I was spot on. I tend to be cautious. You seem to be interested in criticizing me. If that makes you feel better, then go for it.

 

Shipping is not glamorous. The best transits are the boring ones. Yes, shit hits the fan. Been there done that. But when crew has "that nagging feeling we are doing something really stupid, like sailing into a forecasted hurricane" well, that is another matter entirely.

 

We will make sure not to sail together, eh?

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But when crew has "that nagging feeling we are doing something really stupid, like sailing into a forecasted hurricane" well, that is another matter entirely.

 

 

Thoughtful.fw_-300x300.png

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Question re the fire pump:

If I have this correct, there was a seacock feeding a pump that ran the fire suppression for that hold. I am presuming the pump was centrifugal and below the water line. There was a long rod that went up to deck level to control the seacock.

Cargo got loose and hit the fire main, breaking it off below the waterline. Apparently it was not possible to access the seacock directly with the flooding and loose cargo and either no one wanted to go on deck and try the rod or the rod was broken when the fire main was broken.

Do I have this right??

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Not sure if the valve on the sea chest would have a remote operator. A fire pump can range from several hundred to several thousand GPM. I don't know the hold layout of that ship did they reference the hold or deck? I will have to go back to the transcript.

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KIS, I think you're close but it's unlikely that there was a skin valve (seacock in your terms) in that hold. However, the piping was likely somewhat exposed to shifting cargo. More likely it was the suction valve in that tank for pumping out. Not being familiar with the fire main system in a dry cargo ship, I can't say for sure but a hold will have an ability to pump out and, obviously, an ability to input fire suppression water. I suspect no one was willing or able to get to the suction valve on deck and it could have been already damaged via the connection rods (reach rods). I doubt being below the waterline was an issue but if the fire main was effectively filling the hold, you'd certainly be in trouble. Typically, that line can be isolated in one or more places between the hold and the engine room (where the pump was most likely located).

 

I'm still not convinced that the hull wasn't ruptured from loose cargo at this point. The fire main issue may have begun the cascade of events but even then, it would only have been AFTER something got loose to break it. Cargo securing practices may have been somewhat less thorough for 'normal' Carribbean weather conditions as someone else mentioned earlier upthread. Even with good practices, hurricane conditions induce violent enough motion that lashings can be broken. It doesn't take much movement to loosen and eventually part lashings. In fact, given that this ship was both old and a cargo ship with potentially loose cargo, I think the decision to out maneuver and / or approach a hurricane was not an optimum one...

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Do we expect the typical merchant ship to be designed and built to withstand prolonged exposure to the max winds and seas of a cat 3 hurricane? Including dead-ship, if power or steering is lost?

 

What say the naval architects? Tankers, maybe? But bulkers or container ships, with all those holes in the shell and deck plating?

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Ships aren't designed via a first principles approach to limit state sea conditions.* That is simply not how it is done. So you can't actually answer that question.

 

*Longitudinal Strength analysis does consider statistical wave data but this is not an overall limit state analysis of the entire ship design.

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There are a number of narratives being developed in this thread which I would caution all readers to be very suspicious and skeptical of. ALL of this discussion seems to be gleaning almost entirely from the bridge microphone transcript. In terms of real situational awareness, actions by officers and crew, communications etc, this gives a very limited picture and completely misses the bulk of the intra-ship communications. We do not know what or how problems were being discussed away from those mics. Deck officers were communicating with engineering outside those microphones. And engineering is almost completely absent from the microphones (they were in the engine room and control room etc...)

Yes, we all wonder about the weather routing and decisions in that regard. We get some limited sense of discussions to that effect, captured on the mics. But we do not know how much the captain or the mates did in their offices....looking up what was going on...

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There are a number of narratives being developed in this thread which I would caution all readers to be very suspicious and skeptical of. ALL of this discussion seems to be gleaning almost entirely from the bridge microphone transcript. In terms of real situational awareness, actions by officers and crew, communications etc, this gives a very limited picture and completely misses the bulk of the intra-ship communications. We do not know what or how problems were being discussed away from those mics. Deck officers were communicating with engineering outside those microphones. And engineering is almost completely absent from the microphones (they were in the engine room and control room etc...)

 

Yes, we all wonder about the weather routing and decisions in that regard. We get some limited sense of discussions to that effect, captured on the mics. But we do not know how much the captain or the mates did in their offices....looking up what was going on...

 

I think it's only natural that many theories and thoughts appear after reading such a long transcript of real accidents. We seldom get to do that. It was almost like reading the script of a thriller movie, where you got to know the characters quite well before the disaster. The need to understand why and how is a very natural need, because that understanding might prevent more disasters.

 

I also think that most people understand that we will never find out all the details. However, there's a fine line between asking relevant questions, and throwing out hear-say like it's the truth! I'm thinking about the statement from the 2nd mate's mother, saying that her daughter had said the captain was lazy and spent a lot of his time in his cabin. We have no way to know if she actually said this, and even if she did say it, we don't know if she was the kind of person who just doesn't respect their boss not matter how competent they are, or not. Her mother also has an emotional need to put blame on somebody, and perhaps an economical motivation also. So her statement shouldn't be taken for the truth at all, she's biased. All we have is the transcript that documents parts of what was happening.

 

It would have been interesting to hear more about the aftermath. From Wikipedia I read that the company settled with 18 of 33 families (by april 2016). Did the company accept any blame? What about the rest of the families?

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Question re the fire pump:

If I have this correct, there was a seacock feeding a pump that ran the fire suppression for that hold. I am presuming the pump was centrifugal and below the water line. There was a long rod that went up to deck level to control the seacock.

Cargo got loose and hit the fire main, breaking it off below the waterline. Apparently it was not possible to access the seacock directly with the flooding and loose cargo and either no one wanted to go on deck and try the rod or the rod was broken when the fire main was broken.

Do I have this right??

KIS - my understanding is that on typical large ships the firemain serves all the holds, the on deck 'fire hydrants', and also is used to flush heads and for heat exchangers, condensers, and the like. It's kept pressurized at all times. IDK where the seacock/sea chest was located, but I would guess somewhere in the machinery spaces/engine room. It's possible each hold had a valve for its sprinkler system, IDK. Pump would have to be capable of delivering a substantial volume at a pretty high pressure. In case of firemain in hold being damaged and leaking, I think there would be at least two valves capable of shutting it off in addition to shutting down the pump.

Bilge pumps are probably a separate system. In the bit of reading I did, it sounds like big ships have a lot of backup systems and redundancy built in to them.

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Bilge

Ballast

Fire

Ship's Service or General Service

Crossovers between systems
All seachests have shutoff valves

The speculation here is full of flaws and assumptions.

If you want to dig into the weeds you can have at it.
go to eagle.org for ABS rules

go to Subchapter F of 46 CFR

http://www.ecfr.gov/cgi-bin/text-idx?SID=859e7c2e1d0ef211a61f8754a6a3b0fb&mc=true&tpl=/ecfrbrowse/Title46/46CIsubchapF.tpl

and Subchapter I of 46 CFR
http://www.ecfr.gov/cgi-bin/text-idx?SID=859e7c2e1d0ef211a61f8754a6a3b0fb&mc=true&tpl=/ecfrbrowse/Title46/46CIsubchapI.tpl

if you want to know the USCG regulations.

 

if you want to read the U.S.C.G. regulations.

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The superstructure was also found half a mile away. Only four containers remained with the hull. I'm imagining it capsizing, dumping, and filling like a toy boat after the top fell off. The machinery weight low would still give the hull a tendency to right as it plunged to the bottom, especially with the deck cargo gone.

 

My best friend sailed on the El Faro numerous times between Jacksonville and Puerto Rico and wanted to sail on that particular voyage, but was lower on the union list than his friend Roan Lightfoot who took the job. His theory about the separated superstructure is frightening. He said the boilers were located directly below the bridge. He speculates that water breached the compartment with the boilers and hit the boilers causing a massive explosion that blew the superstructure off the ship. He also said the ship was in very poor condition and rusting to death before the fateful voyage.

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Editor’s Note – The following letter was written by Captain John Loftus, a Master Mariner and acclaimed whistleblower with 42 years experience aboard American flagged ships, to Captain Jason Neubauer, Chief of the U.S. Coast Gaurd’s Office of Investigations & Analysis. This letter was published unabridged with the permission of Captain Loftus and Captain Neubauer. –John Konrad

 

“Dear Captain Neubauer,

I write regarding the tragic loss of the Steam Ship El Faro, and your current investigation. My concern, and that of other mariners, is that something may be overlooked. I know your agency tends to be thorough; nonetheless I would like to offer some perspectives, and opinions, based on my extensive experience sailing in the U.S. Merchant Marine.

 

I am a graduate of the U.S. Merchant Marine Academy, class of 1971 Dual License, which means I graduated with both an Unlimited 3rd Mate’s License as well as an Unlimited 3rd Engineer’s License (Steam & Motor). I have held an Unlimited Master’s License since 1978. My career (and personal travel) that spanned 42 years took me to over 100 countries on a variety of different types of vessels, including tankers, break bulk, LASH, SEABEE, and containerships. My first command was with U.S. Lines in 1985 as Master of the American Resolute. At that time, I was one of the youngest Masters with that company since WWII.If your investigation is to be truly thorough, then looking at all possible avenues of approach would seem warranted. This was something I believe you mentioned in your opening remarks, i.e. that the purpose of the investigation was to find out what must be changed, so that future accidents could be avoided.

 

I was engaged as a ship’s Master from 2001 through 2013 on the Jacksonville (JAX) to San Juan (SJU) trade route. This encompassed two container ships, the Horizon Discovery, and the Horizon Trader, where I was billeted as permanent Master.

I know the trade route well and often undocked JAX at the same time as the TOTE ships. Quite often we would sail parallel, in sight of each other, on the way to SJU. I retired in 2013.

 

In regards to this investigation, my position is somewhat unique. Not only did I sail the same trade route as El Faro for 13 years, I was also terminated for reporting regulatory non-compliance issues to both the ABS and USCG. Also, I am the first American Deep Sea Master to bring successful litigation, under the “Seaman’s Protective Act”. Thus in addition to normal seafaring experiences, I also have another side of the story to elucidate. One that is perhaps too often buried, one that companies do not want discussed, one, which can put Seaman, Ships, and the Environment at risk!

 

One of the first statements I remember hearing, which was released by the owner’s (TOTE), when the El Faro went missing, was that they had an experienced and capable Master onboard. Who else would they billet as Master, someone incapable? My very first reaction, and my interpretation, to that statement, was they (TOTE) were setting up the Master as scapegoat for what may be underlying problems, possibly not so noticeable, particularly for those outside the industry.

 

 

https://gcaptain.com/el-faro-open-letter-investigators/

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Best quote from the letter:

 

"13. There is no prudence heading into a hurricane, or trying to cross ahead of a hurricane’s track."

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Man that's a lot of recommendations. I don't know much about commercial shipping or CG regulation thereof, but doubt they will all be taken.

But the central one seems to be missing "Don't try to beat a hurricane"

It does seem that has been learned, however, as watching Marine Traffic during Irma and Maria showed that most all ships gave both storms lots of respect.

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The NTSB excels at recommendations, since they do not have the responsibility for implementing any of them, or paying for the same.  This can and does create some behind-the scenes teeth-grinding in the affected agencies, in this case the Coast Guard.

Yes, the central lesson is not to cut too close to a hurricane, and end up in the eye with your 40-year-old ship.  the Weather Service did not cover themselves with glory either,  

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So many things went wrong, after midnight and before dawn. Little problems developed into big problems, where causes overlapped. Humans have a hard time dealing with this type of situation under stress (anxiety over the storm and age of ship; fatigue; lack of effective communication especially as the storm intensity increased and problems started to occur in different areas of the ship).

I wonder how many of us have done effective emergency drills with everyone aboard that includes the unavailability (due to being off watch or busy working on problems) of key crew members. I must admit I have never ever done such a realistic emergency drill. Sure, the "throw a ring over and pick it up" or even the loss and recovery of someone actually going overboard. But never in combination of other likely complications, such as loss of propulsion in this case, and certainly never abandoning ship into unsuitable life boats in Cat 3 hurricane conditions.

Like the Cheeki Raffiki as well, I wonder how many of us have set off on boats that had unknown fatal flaws.

It really sounds like the ship and crew were doomed about a dozen hours before the ship finally went down, and perhaps even a half dozen years before.

Wow.

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3 hours ago, nolatom said:

The NTSB excels at recommendations, since they do not have the responsibility for implementing any of them, or paying for the same.  This can and does create some behind-the scenes teeth-grinding in the affected agencies, in this case the Coast Guard.

Yes, the central lesson is not to cut too close to a hurricane, and end up in the eye with your 40-year-old ship.  the Weather Service did not cover themselves with glory either,  

 

Eh none of the recommendations are particularly novel or expense in reputable international shipping. 

This particular shipping company and route is a particular joke. PR and other US territories keep the bottom feeding US commercial shipping alive. And by bottom feeding I mean ships and captains with no business in international shipping and can't get insured for freight and cargo on international shipping go to scrape the bottom until the ship is sold for scrap. But can't even make it to India or Bangladesh. 

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That was one of the most heart-wrenching things I've read.  Reading the transcript, and knowing the doom that lay before them, I just wanted someone to say "$@#& it, I'm turning this thing around."  

 

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