It should come as no surprise that of the 11 factors cited by the National Transportation Safety Board (NTSB) in its final report on the loss of the El Faro, the first four fall squarely on the shoulders of the captain.
“The NTSB determines,” the board wrote in the executive summary of the report, published Feb. 7, “that the probable cause of the sinking of the El Faro and the subsequent loss of life was the captain’s insufficient action to avoid Hurricane Joaquin, his failure to use the most current weather information, and his late decision to muster the crew.
“Contributing to the sinking was ineffective bridge resource management on board El Faro, which included the captain’s failure to adequately consider officers’ suggestions.”
As a rule, human factors figure prominently in NTSB accident reports. We are fallible creatures, and in the age of voice and data recorders afloat and aloft, crew errors, omissions, and lapses in judgment are etched in digital stone.
Moreover, it is in our nature to believe that education and behavior modification enable us to overcome our shortcomings and remedy flawed systems. Finding fault with the human component of a tragedy is the first step toward assuring ourselves that it need not be repeated. We believe there is always a solution.
In theory, perhaps there is. As a practical matter, I am not so sure.
The sinking of the El Faro was the culmination of a chain of events. As captain, Michael Davidson was a crucial link. But circumstances conspired against him.
Davidson was hardly oblivious to the tropical storm developing east of the Bahamas. He knew that Joaquin was forecast to become a hurricane. He planned to steam east of the Bahamas as well, but to “shoot under” — south of — the storm on his way from Jacksonville, Fla., to San Juan, Puerto Rico. In this way, he would avoid the worst weather.
Davidson discussed the storm with the ship’s port engineer prior to departing Jacksonville on the evening of Sept. 29. By 6 a.m. the following morning he was in the midst of an hour-long discussion about Joaquin with the chief mate, the voyage data recorder makes clear, and they agreed to alter their course more to the south.
Davidson also told the chief mate he had spoken with the steward about securing the galley, and he instructed him to let the crew know they were in for “some weather,” which, in my experience as a commercial fisherman, is how mariners talk.
He also told the chief mate to ensure that cargo was secure. The chief mate told Davidson that the longshoremen had done it “wrong.” It is not clear from the NTSB report whether this was resolved.
From this point on, the weather was uppermost on everyone’s minds, including Davidson’s. By early afternoon, long before it got rough, the ship had passed the point where it might have altered course to pass under the lee of the Bahamas, a subject of discussion among crewmembers. This would have meant passing though relatively tight quarters south of the Great Bahama Bank, but it was a passage he had made a couple of months earlier, during a tropical storm. The captain noted that Joaquin had yet to make its expected turn to the north, but he expressed confidence in his ship.
Ironically, the next significant turn the El Faro made was not to the south but to the northeast, to contend with an increasing list. Not long after, the vessel lost propulsion, at which point the die was cast.