The mental model that was formed by the experienced and by most accounts safety conscious captain of the El Faro, Michael Davidson, turned out to be so flawed as to be fatal, especially when combined with the shortcomings of the old, shabby ship he captained.
Davidson gradually steered his ship into a trap, resulting in the deaths of 33 crewmembers. This despite the fact that at the time of the ship’s departure, Davidson was aware of the weather and planned to remain south of the storm.
The trap was as much a construct of his mind as it was a case of a hurricane that defied forecaster’s best efforts — one that “didn’t do what it’s supposed to do.” Hurricanes aren’t “supposed” to do anything in particular, they just are. People forget this fact at their own peril. Any mental models built on the presumption that getting close to a major storm is “okay as long as … ” are flawed and foolish.
Members of the crew seemed to have much better mental models of what was going on, but were unable to puncture the dome of institutional hierarchy that allows captains to operate in a bubble. That failure cost them their lives.
As far as shoreside management was concerned, their mental model appeared to be virtually non-existent in regards to vessels that operate in close proximity to a known tropical cyclone that was rapidly intensifying or otherwise. There was no clue at all that anything was amiss until the first phone call came in. That’s not a good way to operate, and is at the very least extremely irresponsible if not negligent.
So this is a warning to look at your own procedures, practices and mental models with a skeptical and critical eye. Once again I urge you to take a look at Laurence Gonzalez’s now seminal take on the subject, “Deep Survival.” It should be required reading for everybody.
Afloat and shoreside, regulators and the regulated, it’s clear that we need to think differently, very differently, if we really want to avoid these types of avoidable tragedies as we claim we do.