El Faro and mental models – Part II

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.

About the author

Joel Milton

Joel Milton has worked aboard fishing boats, pilot boats, Coast Guard cutters and small boats, dredge tenders, offshore crewboats and supply boats, towing vessels, a small container ship, and a wide variety of small craft including an inflatable yellow “ducky” The Piker.


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    I told the coast guard and NTSB all this when it first happened. People called me a liar and disgruntled. Not looking so disgruntled anymore facts are facts. Tote Maritime got away with murder

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    John Dapper on

    I operate in the North Pacific and haven’t been in East Coast waters in a long time. But for some reason I followed that hurricane from about a week before the El Faro disaster. I remember thinking that any ship coming down the coast would either have to go far to the east or take the inside passage down the Florida coast. Then El Faro comes along and heads right for what I suspected was the likely storm track. If I can figure this out, why can’t a captain that’s been in those waters continuously. Probably scheduling pressures from Tote.

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    Still no reason to be that close to an unpredictable storm. You might as well run thru railroad crossings before the train crosses because you have impeccable timing and are really good at driving. In reality, responsibility falls to the Captain. He got everyone killed because he was stupid. He didn’t listen to his lower officers even though they told him the current track of the storm. He didn’t think he would lose propulsion in the storm. He did. He didn’t take the appropriate measures to miss the storm but instead placed his vessel in a direct route with tragedy instead of increasing his odds of survival by staying as far away as possible. For those making the case that if he went west, he would of got fired for delay to the vessel schedule. He wouldn’t of gotten 33 people killed but he would of been fired. Do you know how stupid that sounds? Still, his job isn’t worth putting 33 people’s lives at risk. Going forward, guess what the next vessel will do when a storm is nearby? You think they’ll charge right at the damn thing thinking everything will be ok or will they give pause and stay well away from the storm? Learn from this tragedy or else.

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