El Faro and mental models

It’s not a pretty picture, no matter what angle you view it from. The findings from the U.S. Coast Guard and the National Transportation Safety Board after concluding their separate investigations of the now infamous sinking of the 790′ El Faro in the Bahamas on Oct. 1, 2015, are sobering stuff.

In spite of the fact that various parties representing various interests will continue to dispute portions of the Coast Guard and NTSB reports, the many failures and shortcomings that led to the disaster leave no one untouched.

Poor situational awareness, aided and abetted by inadequate professional training, an ineffective safety culture afloat and ashore, and an unwillingness to consider worst-case scenarios and possible alternatives to avoid them, led directly to a series of clearly bad operational decisions. But these decisions did not occur in a vacuum. A complete lack of checks and balances, both on the water and ashore, resulted in the voyage gradually snowballing into a mass-fatality disaster. Insufficient safety support and oversight from every level — corporate, regulatory, etc. — laid the foundation for it all to unravel, resulting in the deaths of 33 crewmembers for no good reason at all.

There is much to think about, but I’ll point first to remarks made by NTSB Chairman Robert Sumwalt at one of the hearings in Washington, D.C. Referring to the El Faro’s captain, Michael Davidson, he said, he “had a mental model that the hurricane would be in one place, and based on that mental model and based on his previous experience he thought they were going to be OK.”

That mental model proved to be wrong, and with fatal consequences. Since we all build mental models for everything we do (even if you’re unaware of it) and no one is immune from building a bad one, you might want to consider the serious ramifications of that fact.

As for the value of experience, consider this: Davidson’s previous experience did not help him and probably pushed him further into a corner from which there was no escape.

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 am sure that many have been in these shoes- and survived- we call that experience-
    but I can also suggest that if the supporting input of data provided a direction, the gut was always second fiddle to “the experts and employer” which so surmises the always present master.vessel vs the office-

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    Nobody did anything right. I have 32 years at sea ending as a chief engineer. I know enough to read weather forecasts, weather faxes, and storm reports. I can read the date and time on them. Nobody brought the captain’s attention to the current status, and did so as forcefully as necessary to get his attention. Did the young chief engineer dump all the oil on board, of any type, into the sump to help the oil pump pick up suction while the ship was heeling? Any oil is better than no oil. Did the extra chief engineer on board supervising the riding repair crew offer any assistance?

    That ship was 39 years old. It is impossible to inspect everything, to be sure every possible weak point is as good as new. Extra care needs to be taken with ships that are possibly weakened by deterioration, and every 39 year old ship, and half that age, is included. The scuttle that came open was a symptom of the problem. Either it was left open, and that was the problem…lack of manpower or will to fully inspect the ship before sailing…or it was worn and needed repair before the ship went to sea. Either was a failure of both the people ashore and the people aboard. Somebody needed to step up regardless of how tired and overworked they were or how intimidated they were by the terrible ownership.

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    As a captain of a offshore towing vessel I have had this same problem as I’m sure this captain did the office personal want to run the vessel from the office with zero experience and if you challenge their decision the battle begins and we all know that the end result is you will not be employed very long after if you stand your ground they will not fire you right away but the first infraction you commit that will be the reason they let you go and it’s a small community and you will be labeled that you are not a team player and difficult too work with until management is held to the same level as the Mariners are i see no hope of correcting this problem.

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