NTSB goes overboard faulting El Faro skipper — Part I

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.

 

About the author

Jerry Fraser

Jerry Fraser is the publisher of WorkBoat Magazine and WorkBoat.com.

19 Comments

  1. Davidson was totally responsible for putting the El Faro in a position that it could not recover from. He probably did that to impress Tote Management in order to seek a transfer to a new ship. Also it was poor judgement to rely on weather reports that were not current because it was easier that keeping track of the storm himself. Lastly not to abandon ship in a time,y manner played a large part in the loss of all lives.
    I completely understand protecting reputations but I also understand he was the primary link in the error chain

    • Davidson was pressured and also thought of himself. Tote didn’t care about our safety. They only cared about was getting that cargo on time. ABS was bought out by Tote. Coast guard did t have the funds to monitor.

      Speed and Greed killed all 33

  2. I told all my friends shortly after the El Faro sank that no matter what is said in any report, after all the finger pointing, dodging & weaving by management, and all the other, various considerations, ultimately, the Captain will be blamed.
    And so he was.

  3. Ultimately it IS the captains responsibility and it has always been since man has gone to sea. The question is WHY did the captain not alter course to go south under the Bahamas?
    Unfortunatly we will never know for sure. And second guessing is just that second guessing.

  4. I spoke at the World Maritime Rescue Congress, Bremerhaven Germany, June 2015 – on certain issues regarding maritime safety.

    One of my slides was titled – “It is the Captain’s Decision whether to sail; It is the Owner’s Decision who is Captain (along with a picture of the Charles S Price, lost with all hands in the Great Storm of 1913).

    There you have it in s nutshell – the ‘Old Man’ is in a virtually untenable position.

    He must take his share of the blame; however, if you want things to improve – those ashore, particularly in the Regulatory Agencies, should admit their errors. To large extent the USCG has had ‘the balls’ to do this; other organizations have not.

    Read also Canada’s response to the ‘Lac Megantic disaster’, where only the front line ‘scapegoats’ have been held accountable (acquited by the jury without the defence having to call any evidence; more importantly acquited by the relatives of the 47 victims).

    My presentation in Germany can be found here:
    https://international-maritime-rescue.org/presentations-downloads-download/tuesday-2-june-2015

    • Agree with all, but wish to refer back to CG report on the loss of “Marine Electric”-which made clear that inspections were a farce. One of the Board, Captain Callichio scuppered his career by pressing for USCG to up it’s inspections

  5. The NTSB report rightly faulted USCG for inadequate monitoring of the Delegated Inspection agency, and rightly faulted the Delegated Inspection agency for inadequately rigorous inspection of “El Faro”. NTSB was also rightly critical of the Master’s decision making. The only person that emerges with any credit is the now-deceased Second Mate, who advocated passing South of the island chain, a decision which, had it been put into effect, would probably have led to a completely different outcome.
    One thing that I do not think was given adequate weight was the fact that ferries are locked into tight schedules. The Master and crew are under constant time-pressure. Having sailed on ferries across the English Channel, I am aware that the clock usually has the deciding vote in every decision. For this reason, the Statement of the Master’s Over-riding Authority, which is incorporated into the I.S.M. Code is vitally important, and any company which fails to back the Master 100% if he/she decides to delay sailing/slow down/take an alternative route is on the slippery slope to disaster.

  6. “…circumstances conspired against him”. No, the Captain should of never been within 67 miles of a hurricane. I don’t care what direction the storm was supposedly going or not going based on weather reports. Do you play chicken with a train just because its on a track and your timing is impeccable? No, that’s just being irresponsible and nuts. Bragging about being in the Gulf of Alaska in ‘similar weather’ is further evidence he was not clear in the head. A circulating natural disaster is totally different than being in head/following/quartering seas in one direction. A hurricane is a blender at sea. Your vessel is at mother nature’s mercy and you better hope your equipment doesn’t fail or else. Too risky. Being the “boss” onboard means you are responsible for whatever happens. You minimize your risk for your crew first, cargo second. None of that was done. All I see is “we need to get there fast to miss the storm”. Nuts. And now he’s ended the lives of those who put their trust in him. Fully his fault.

    • Jerry Fraser

      We can agree that the El Faro should not have wound up as close to the storm as it did. But we have to consider how it got there. Captain Davidson made the decision to stay east of the Bahamas based on the information he had at the time — many hours before things got out of hand. My reading of the report is that by the time it was apparent that a beating at the hands of Joaquin was all about unavoidable, the El Faro would have had to steam back to Great Abaco Island and up through the Northwest Providence Channel to position itself to pass beneath the Great Bahama Bank.
      If Davidson had flipped a coin and said, “To seaward it is,” I’d view him a lot more harshly.

      • Randy Stambaugh on

        Davidson made very little effort to get clear, reliable facts in front of him to make a good decision and it’s unbelievable that he did not consider the consequences of making a poorly informed decision. There is no question that he placed himself under great pressure to get that cargo delivered on time and crew safety was a distant afterthought.

    • Your opinion is based on certain information without all the facts. Everyone is entitled to their opinion… My opinion is unless you were there and knew all the facts, keep your biased opinion to yourself. You really know very little of the situation or the people involved.

      • Chris who are you? Please tell everyone who you are. Everyone agrees that Tote Maritime and Captain totally screwed up. I was on EL Faro and saw what a lazy captain Davidson was. I saw whenever we reported a safety issue nothing was done about it from the company. I’m not afraid to say who I am. Why are hiding, don’t be afraid.

      • Yeah, my ‘biased opinion’ is the problem, not the error chain that started and finished with the Captain in his watery grave along with 33 others he was responsible for. I’m a mariner pal. Read the emails sent by the different crew members. Read the email the Captain sent to the office giving his probable position relative to the hurricane. It doesn’t take a meteorologist to realize getting 67 miles within a hurricane eye is a bad idea. Even the 2nd Mate said so in her email. But, that’s just my ‘biased opinion’. The Captain is responsible. You can blame God, Allah, the tooth fairy, bad luck, having bad day, etc. but the FACT remains, the Captain should of never put his vessel in this situation EVEN if TOTE told him to. You tell TOTE we’re going west through the hole in wall until the storm passes and you can fire me when I get to shore. He used the west route before. No reason to think he couldn’t do it again. The schedule wouldn’t of changed by much, the crew would be alive, and the cargo would of made it to port. I stand by my ‘biased opinion’.

  7. I used to think that the NTSB was a “facts only” organization, that told it like it was. It may be, to varying degrees, but they are also capable of straddling a political fence as well. Their report on an accident that my vessel was an assist boat in pretty much flew in the face of what actually went on, and ignored the fact that even mildly knowledgeable people would have never made decisions that their report inferred. Due to this incident, I lost a lot of faith in an organization that I thought was above that kind of behavior. It’s very convenient to blame Michael Davidson, He’s no longer on this earth to defend himself. And after all, what is a license but a convenient way to hang someone small when things go wrong.

  8. John C. Kimbrough on

    I am not a mariner so I know little or nothing about going to sea and seamanship. From my extensive reading and research into this tragic accident however it seems to me that Captain erred in perhaps a number of ways. This sinking could have been avoided. God bless those who lost their lives. And God bless those men and women who go to and work at sea for a living.

  9. Never trust an old ship; yet pushing it through a storm with speed and waves is seeking ones chances.

    No heave to just a focus on running for ETA’s. Push Push push seems much to the the task of Senior Mgt.

    Nevertheless, they were lost in dedication to their task and I salute em to the last.

  10. Master Martin on

    For the shore based “specialists “ who have never seen a ship and would crap their pants when they cross 3 ft waves, I have been a professional master mariner for over 10 years and have seen dozens of hurricanes and other bad storms develop in front of me. I wouldn’t call myself an expert but know how to recognize a bad hurricane when I see one. And Joaquin was obviously one of those one would stay well away from.
    Not to point a finger on one or the other professional, specially when they are not here to defend themselves anymore…but to learn for the future.
    The Atlantic Ocean is big with plenty space to run away from harms way with such monster storm approaching. Whatever the company does or not press the captain, he remains in charge and responsible for safety. Eventually better not being a captain than a dead captain…
    All tools are available, the US National Hurricane Center sends out at regular intervals actualized forecasts about each active tropical cyclone. Yards of paper would run out of the Inmarsat C receiver… I’d be plotting the track on an actual see chart every 6 hours and not take the slightest chance.
    There is simply no excuse to rely on outdated data. And how far would it have been outdated in this case? To come so close to the storm and not knowing where it would go is far out of this modern time. All the tools are there to avoid such close encounter. Anyone who reads the forecasts would know that no one wants to be there were he was thinking to go… And a missing wind meter makes no difference in such situation. Looking out of the window is more than enough to see what wind comes from where. And no company would send a ship and crew to such place and even if they do, the captain is legally covered to follow his own instincts and run for life. And if he would get fired? Then it’s time to pack suitcases and go home, such employer is not worth working for.
    I have once been in a situation the owner wanted to send me to sea against any common sense with a cat 4 hurricane approaching and everybody searching for cover and literally nobody leaving port. I ended having the last word and persisting on my authority. Behind a a desk looking at the blue sky through the window is easy… When next hurricane came and ran over their office’s roof they must have nearly crapped their pants and were far less concerned about being on schedule…

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