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The Worst U.S. Maritime Disaster in Decades
- cesarb 8y agoNTSB report: https://www.ntsb.gov/investigations/AccidentReports/Reports/MAR1701.pdf https://www.ntsb.gov/investigations/AccidentReports/Reports/...
- dz0ny 8y agoIt still boggles my mind how three different GPS position formats can be used. And then not used correctly by search crews, which then missed location by 23nm. https://i.imgur.com/nbwkCPY.png https://i.imgur.com/nbwkCPY.png
- thaumaturgy 8y agoYeah, coordinates are a pain in the ass, and here they're even using the same coordinates, just with different formatting. There's also UTM, deg-dec-min, deg-min-sec, and you have some differences between WGS84 and NAD27, and every group has their own preferences for their own reasons.
- fwip 8y ago23 nanometers off, dang. If they'd only had a slightly wider field of view, they could have found those poor people. :(
- AceJohnny2 8y agoNautical Miles
- bjt2n3904 8y agoPerhaps a little poor taste with the tone, but this is a great point. We're all talking about how poorly we handle units. Nm has two meanings, but I didn't even think about it until this comment.
- thisrod 8y agoThose formats are simply insane. It's well known that some people use decimal fractions of degrees, so why would anyone even consider using a decimal point to separate degrees and minutes?
- dreamcompiler 8y agoWas this a big problem before computers? I doubt it. Back in the analog days two people would engage in a dialogue and ensure the units were agreed upon. Now people just blindly type data into a screen, or two computers blindly exchange packets without proper metadata. It's ironic that we have 1000x better navigational accuracy than a 19th century tallship captain but we're much more careless with the data than he would have been.
- thisrod 8y agoI don't think it's carelessness, rather that 1000x more accurate navigation gives you a lot more things to care about. That 19th century captain measured the angle between the pole star and the local horizon with a sextant; the cartographers did it the same way, because that was the only thing you could do. Today, we work with atomic clocks, and our instruments fabricate an angle between the z-axis and a 100th order spherical harmonic series that models the shape of the ocean surface. Every few years, we update the model to keep up with plate tectonics. (Not exactly, but you get the idea.) There are a lot more things to go wrong, and not everyone programs in sanity checks to prevent small corrections from causing large errors.
- dreamcompiler 8y agoFair point. > That 19th century captain measured the angle between the pole star and the local horizon with a sextant; Which immediately provided latitude. To get longitude, he did the same with just about any other star and correlated the angle to an accurate clock and carefully-prepared tables. That "accurate clock" business was why longitude was such a difficult navigational problem for so long until John Harrison finally cracked it. (I know this is getting OT but I find it fascinating.) https://en.m.wikipedia.org/wiki/John_Harrison https://en.m.wikipedia.org/wiki/John_Harrison
- Nrbelex 8y agoSee also an in-depth report from the AP: https://apnews.com/9d5904f83f6a4cf784828107fa7d038d https://apnews.com/9d5904f83f6a4cf784828107fa7d038d
- Luc 8y agoI could tell from the title this was going to be written by William Langewiesche. He really knows how to spin a good yarn. All his articles and books seem to be movie-worthy. I'm not entirely convinced reality is that exciting, though.
- jonathanberger 8y agoIf you like this article, I recommend finding his other pieces particularly about airplane crashes. He writes in a gripping manner and normally seems to have done pretty thorough background research, as well as personal experience.
- SeanBoocock 8y agoA great example is his treatment of Air France 447: https://www.vanityfair.com/news/business/2014/10/air-france-flight-447-crash https://www.vanityfair.com/news/business/2014/10/air-france-...
- Stratoscope 8y agoOh my, you weren't kidding: On the last day of May in 2009, as night enveloped the airport in Rio de Janeiro, the 216 passengers waiting to board a flight to Paris could not have suspected that they would never see daylight again, or that many would sit strapped to their seats for another two years before being found dead in the darkness, 13,000 feet below the surface of the Atlantic Ocean. But that is what happened. And I thought that name sounded familiar. William is the son of Wolfgang Langewiesche, author of one of the books that taught me how to fly: Stick and Rudder. https://en.wikipedia.org/wiki/Stick_and_Rudder https://en.wikipedia.org/wiki/Stick_and_Rudder
- brightball 8y agoThat was hard to read.
- Baeocystin 8y agoDamn. That was intense. Thanks for posting this.
- V2hLe0ThslzRaV2 8y agoDoes anyone know if the investigators checked to see if the captain may have had reasons to sink the ship? Beyond that, given the captain's body was never recovered, were investigators able to confirm that communications were coming from the positions reported by the captain? RELATED: Here is the US Coast Guard Marine Board of Investigation final report on El Faro[1] -- in which the investigators had stated that if Davidson had survived the storm, his actions would have been grounds for the Coast Guard to revoke his captain's license. What I am not seeing in the report is any reference to if the investigators checked to see if there were any reasons in his personal life that may have caused the captain to intention sink the ship; for example, recent suicide attempt, recent diagnosis of terminal illness, financial issue, employer or family issues, etc. [1] https://media.defense.gov/2017/Oct/01/2001820187/-1/-1/0/FINAL%20PDF%20ROI%2024%20SEP%2017.PDF https://media.defense.gov/2017/Oct/01/2001820187/-1/-1/0/FIN...
- aglionby 8y agoThis seems unlikely given that the captain was looking for a new position as captain on one of his company's new LNG ships. You may find section 1.8.1 of the NTSB report[0] interesting; it goes into more detail about the crew than the report you linked. Maybe more relevantly, section 2.6 details his decision-making. [0] https://www.ntsb.gov/investigations/AccidentReports/Reports/MAR1701.pdf https://www.ntsb.gov/investigations/AccidentReports/Reports/...
- V2hLe0ThslzRaV2 8y agoReport clearly states he needed money and the captain though it was likely the company was going to screw him over based on verbal second-hand accounts of drinking under his watch. Near the section you referenced it does state that the investigators checked the captain's most recent medical exam report.
- thaumaturgy 8y agoFWIW, this scenario is what many people jump towards in missing-persons cases, and it so far has not been true even once in my experience. It does happen, but it's much rarer than a straightforward combination of bad circumstances and bad decisions. Hell, at this point I've seen more murders and probable murders than people disappearing on purpose.
- nradov 8y agoThe El Faro sinking has also been covered extensively from a professional mariner perspective on gCaptain. http://gcaptain.com/tag/el-faro-investigation/ http://gcaptain.com/tag/el-faro-investigation/
- jtwaleson 8y agoThe article mentions that there are major merchant vessels sinking every two/three days! That seems huge. How many deaths per year does that amount to? We're lucky to be in tech I guess.
- matte_black 8y agoNever ever underestimate how lucky we are to be in tech.
- mannykannot 8y agoA recent (paywalled) article in the New Scientist stated that the fatal accident rate for ships' crews is twenty times that of the average British worker. https://www.newscientist.com/article/mg23731623-300-ghost-ships-the-autonomous-vehicles-making-waves-on-the-water/ https://www.newscientist.com/article/mg23731623-300-ghost-sh...
- gsnedders 8y agoHow does the fatal accident rate for, e.g., professional drivers compare with the average worker? I imagine crewing a ship is more dangerous, but humans are famously bad at evaluating risk.
- Latteland 8y agoSo being crew on a merchant ship is more dangerous that cops (by far), and probably more dangerous on say a 10 year timeframe than being in the military (since you probably aren't at war that much over 10 years, unless you are unlucky).
- michaelt 8y agoFor the British merchant fleet, 19.5 deaths per 100,000 seafarer-years [1]. For American loggers, 90 deaths per 100,000 worker-years [2] making it the most dangerous job. For American taxi drivers, ~18 deaths (of which 8 are murders) per 100,000 full-time-worker-years [2]. Making taxi driver the most murdered profession - and it was worse around 2000, when the rate was an eye-watering 23.7 murders. As you say, policing isn't the most dangerous profession; the rate there is 11 deaths of which 3.5 are murders. [1] https://academic.oup.com/occmed/article/64/4/259/1464740 https://academic.oup.com/occmed/article/64/4/259/1464740 [2] https://www.washingtonpost.com/news/wonk/wp/2015/01/28/charted-the-20-deadliest-jobs-in-america/?utm_term=.d37ea0bcc324 https://www.washingtonpost.com/news/wonk/wp/2015/01/28/chart...
- sdhgaiojfsa 8y agoMy big takeaway from all of this is that, given the choice between driving your boat into a hurricane and doing something else, something else should be the default.
- bklyn11201 8y agoAnother conclusion was that a tiered subscription model that withholds life-saving information is a business I never want to be in. El Faro subscribed to the Bon Voyage System for weather updates, but they didn't subscribe to the routing guidance and always received six hour-old information. The stale data is a critical part of this story. http://www.stormgeo.com/solutions/shipping/on-board-services/bvs-routing/ http://www.stormgeo.com/solutions/shipping/on-board-services...
- yread 8y agoAnother important part are the flashy graphics. People always trust you more with flashy graphics against a list of coordinates
- radicalbyte 8y ago..and buggy software.
- hinkley 8y agoAs a professional curmudgeon, I have the same reaction to shiny graphics that I do to salesman I’m fancy suits: I’m not buying. Charting data accurately is really really hard. On one team we had a guy who said charts are for asking questions, not making decisions, and I’ve found that to be a pretty safe default.
- user5994461 8y agoAnother conclusion is to never be in a business that tries to save pennies by not subscribing to life critical data.
- dmix 8y ago
- clon 8y ago> She called Davidson on the house phone and told him that the hurricane was now a Category 3. He knew that already. She proposed the escape route to the south and a smooth sail on to San Juan. He rejected her suggestion. I wonder if in the maritime world there is the equivalent of CRM (Cockpit Resource Management), as in aviation. Too many lives were lost due to 1st officer never taking over command when the error in the commander's thinking had already become apparent or the entire aircraft was being flown, effectively, by a single infallible captain and not a team. Lessons were learned decades ago and at least in a 1st world outfit I would like to believe that no 1st officer would hesitate to utter the words "I have control" when in such stress.
- aglionby 8y agoThere is: bridge resource management. It actually grew out of CRM. Section 2.7 of the NTSB report (linked elsewhere in this thread) gives an overview of it and discusses how it played a role in this incident. It's an interesting read and seems to be relatively in-depth.
- clon 8y agoLearned something today, will research it. Thanks!
- aglionby 8y agoThe comments by the board members on pages 256-259 discuss this as well. The second statement is interesting in particular as it talks about the differences in crew hierarchy between aviation and maritime.
- scrollaway 8y agoReading through Section 2.7 of that report was a treat, thank you! (https://www.ntsb.gov/investigations/AccidentReports/Reports/MAR1701.pdf https://www.ntsb.gov/investigations/AccidentReports/Reports/...)
- 8y ago
- dwighttk 8y ago>Fisker-Andersen wrote, “Captain Mike, diversion request heads up through Old Bahama Channel understood and authorized. Thank you for the heads up. Kind regards." I'm not quite following that sentence. The article makes a lot of the "authorized", saying that meant the captain was being ordered to go directly to San Juan and not use the Old Bahama Channel. However, it seems to say that the diversion into the channel was authorized.
- aniro 8y ago>Question I would like to transit the Old Bahama Channel on our return northbound leg to Jacksonville, Florida. This route adds an additional 160 nm to the route for a total of 1,261 nm. We will need to make around 21 knots for our scheduled 10/05 10:45 arrival time at Jacksonville pilot station.
- dwighttk 8y agooh, ok. So the presence of "authorized" in the response email brings up the question of routes in general being authorized by corporate. It isn't an order to go directly to San Juan.
- phlakaton 8y agoRight--the authorization we saw was for the return trip, and the question was what that might have implied about the trip down. The NTSB report notes that, earlier that year, during Tropical Storm Erika, the Captain felt no need to ask for authorization when changing course--he just made the change and notified HQ. This time, with his job on the line and future career in doubt, he seemed less willing to act independently. The NTSB concluded that they had no solid evidence that the company was applying direct pressure for him to stick to the route, but they did note a whole host of implicit pressures, as well as a relative deprioritization of safety and crew management in the company culture as a whole, that might have adversely affected his decision-making.
- bklyn11201 8y agoThe difficulty of "authorized" was that a captain at sea should have full control to make safe navigational decisions without corporate, profit-minded authorization. Captain Mike's previous experience insinuated that a captain could override company orders but could expect to be quietly let go soon after.
- doughj3 8y agoFor anyone interested in stories like these, I highly recommend "Normal Accidents" by Charles Perrow - there's an entire chapter on maritime accidents.
- Analemma_ 8y agoSeconded, Normal Accidents is one of the best books I've ever read. In addition to the maritime accidents, there are chapters on nuclear plants, chemical plants, and dams. It is a great discussion of how modern industrial accidents rarely have a single cause but instead are cascade failures of systems whose complexity has evolved beyond what we can handle, and presaged many of the messes we've got into with hyper-scale software projects before those ever existed. Is there a "sequel" to Normal Accidents about software? Because I'd buy that in a heartbeat.
- tbihl 8y agoThere's a book that seems similar to what you've described, called Atomic Accidents. It's a compelling narration of many notable mishaps in nuclear power, weapons,and research. Needless to say, it won't scratch the software itch.
- lazyant 8y agoSomehow related, "Command and Control" is an excellent read.
- MarkMMullin 8y agoCheck out stuff that Betrand Meyer, Eiffels dad, has written - he pretty much beat hell out of software mishaps to show how he'd tried to compensate for those issues in Eiffel. -- here's one of the best known -- https://archive.eiffel.com/doc/manuals/technology/contract/ariane/ https://archive.eiffel.com/doc/manuals/technology/contract/a...
- dredmorbius 8y agoComp.risks has a lot of raw source material, and its moderator, Peter G. Neumann, has published a few books. Ex-Goggler Yonatan Zunger has had some really good recent essays at, variously, Medium, Twitter, the Boston Globe, and Google+ (for which he was chief architect, and despite its general lack of widespread success, I consider his contributions and lessons-learned experience quite positively). And he's a fan of Perrow. Bruce Schneier's work is somewhat more focussed on crypto and security, but covers much this ground, especially later works. Shoshana Zuboff also addresses social impacts of computers and data systems in her work.
- gregschlom 8y agoI don't see anyone here commenting on this, but there's an interesting software / UI angle in this story: the captain preferred the fancier, animated-map-style weather reports from a 3rd-party company (B.V.S. reports) to the more terse text-only reports from the National Hurricane Center (sat-C reports). Turns out, the B.V.S reports were using raw data that was 10 to 12 hours old - and they didn't explicitly mention that. In the case of a rapidly evolving hurricane, it mattered a lot. > The B.V.S. map included a time stamp that showed when the processing had been completed, but gave no indication of the age of the raw data on which the forecast was based. Davidson knew that all the forecasts were uncertain, and that they sometimes disagreed. But how aware was he that when he looked at the B.V.S. maps he was looking into the past? [...] > Davidson dismissed the plan with a thank-you and did not come to the bridge. Evidence suggests that he was still showing a preference for the animated B.V.S. graphics, which indicated the storm progressing more slowly.
- r00fus 8y agoIs that really a UI issue or misrepresented data? If I see a timestamp on rapidly changing data I sure as hell would like to see if there's a delayed effective stamp (most stock market tickers indicate the "effective date" of their data or say clearly there's a XX min delay).
- anonoholic 8y ago> Is that really a UI issue? More of a UX issue. The worst possible kind.
- forapurpose 8y agoYes, I saw the same thing. Even when I've had people reviewing logs, I make the date prominent and train them to check it first. BVS's data is far more critical. (I learned from a burnt hand: We engaged a non-technical but reliable user to check the daily backup log for errors and report any to us. One day we needed the backup and discovered it hadn't run at all for many weeks. Ouch. I asked the user; she said she indeed checked the logs daily and they were fine. She was right: She was seeing the log from the last backup, unchanged every day. My fault entirely, not hers: We should have anticipated the date problem, and we should have utilized someone technically literate enough to understand what they were reading - in this case, someone who would recognize an 'obvious' problem such as the numbers of files and bytes not changing. And we should have tested our backups more often, but that old lesson almost isn't worth mentioning.)
- BuffaloBagel 8y agoWonder why shippers don't have a 24/7 Operations Center employing meteorologists and tracking weather systems and ships and in close contact with ship's crew. It struck me that there was a lot of friction for the crew to just plot up-to-date weather/forecasts and the ship's course. Crew was constantly fighting for current data and good/correct visualization.
- jfaat 8y agoCost, most likely
- mjn 8y agoI don't suppose anyone here knows whether this plays out differently with very large shippers? I could imagine that having a real 24/7 in-house operations center could be cost-effective and desirable for a giant line, especially one like Maersk that is both huge and somewhat reputation conscious. But I have no idea whether they do.
- foobarbazetc 8y agoDepends on the line. Most big names do.
- YeGoblynQueenne 8y agoBridge transcript, addenda and errata: Voyage Data Recorder https://dms.ntsb.gov/pubdms/search/document.cfm?docID=447547&docketID=58116&mkey=92109 https://dms.ntsb.gov/pubdms/search/document.cfm?docID=447547... Errata to Voyage Data Recorder https://dms.ntsb.gov/pubdms/search/document.cfm?docID=455021&docketID=58116&mkey=92109 https://dms.ntsb.gov/pubdms/search/document.cfm?docID=455021... Addendum to Voyage Data Recorder https://dms.ntsb.gov/pubdms/search/document.cfm?docID=455022&docketID=58116&mkey=92109 https://dms.ntsb.gov/pubdms/search/document.cfm?docID=455022... Attachment 1 to Addendum to Voyage Data Recorder https://dms.ntsb.gov/pubdms/search/document.cfm?docID=455023&docketID=58116&mkey=92109 https://dms.ntsb.gov/pubdms/search/document.cfm?docID=455023...
- dmix 8y agoIs the audio available from the deck?
- YeGoblynQueenne 8y agoI didn't see it anywhere. Oh man. That transcript was the single worst thing I ever read in my whole life.
- chrisweekly 8y ago1. FYI the article is new but the disaster described happened on October 1, 2015. 2. I was astonished at this: > "It has been reported that a major merchant ship goes down somewhere in the world every two or three days; most are ships sailing under flags of convenience, with underpaid crews and poor safety records."
- Someone 8y agoAs to point #2: https://www.fleetmon.com/maritime-news/?category=incidents https://www.fleetmon.com/maritime-news/?category=incidents has a sobering list.
- dredmorbius 8y agoThe shipwreck rate staggerred me when I ran across it a few years back. It's the key reason I don't find commercial marine nuclear propulsion viable.
- myrandomcomment 8y agoWow. I know it is long, but read it if you have not. It’s very....human.
- foobarbazetc 8y agoWhat’s really interesting about this is the sort of horror film aspect to these situations where everyone gets a bad feeling of impending doom but they push forward anyway. People should trust that instinct. Takes a lot of effort to pull away from the brink, but you should do it. 100% of the time.
- oldmariner 8y agoSome don't recognize the situation is bad because of ignorance. Some don't pull back because of cowardice. The rest keep on going because of the sense of adventure. It makes you feel alive.
- AnatMl2 8y agoAgreed. Although, by changing the rout a couple of times they were pretty much following their instincts [alongside the weather reports].
- boomka 8y agoThe article pointed out that couple years earlier the captain did exactly as you suggest and pulled away from the brink because of safety concerns. His company punished him immediately with a big demotion. It seems clear that the culture in the industry is set up to weed out those who want to err on the side of safety, and reward those who err on the side of maintaining their shipping schedules.
- deadwing0 8y agoAnyone else get a weird pop-up after opening this article? I'm using Firefox for Android, and after I open the article and begin scrolling, a little box pops up that lists the names of 2 local financial institutions and the word "remove." As I scroll down, the box moves, too. If I tap on one of the names or the word "remove" the box disappears. I only get this on Firefox for Android. The only reason it's rather worrying is because I happen to bank at both of the financial institutions on the list. They are both small, local institutions. Tried opening the link on a couple other devices but was unable to recreate this. The pop-up appears every time I open the link in Firefox on my phone, though.
- leeter 8y agoWhat amazed me reading the report was just how vulnerable the ship was to sinking if it had a list during a storm. While an 18 degree list is extreme it's not unforeseeable in a serious emergency. The problem was this put ventilation openings at a height where they were directly subject to green water infiltration. To make it worse only the intakes were 'watertight' the exhausts were only 'weathertight' meaning that this would have resulted in flooding that would have made the problem worse.
- Shivetya 8y agowell there is a big gulf between storm and hurricane. if they had encountered a normal squall it is doubtful they would have been in trouble but they ran straight into a CAT3 hurricane which if you have experienced on land you know its not even remotely sane to be out in it.
- leeter 8y agoTrue, but if you read the report even under non-insane circumstances the design of the ventilation system would have put the ship at risk in any gale or full gale situation. The main issue was the intakes were on the tween deck instead of the main deck and were outboard. Thus if the ship listed at all to the point where the tween deck was even partially submerged it risked serious flooding. This seems counter to the design of the ship where the tween deck was supposed to be open to the sea, but not awash certainly, but still in theory all fittings an openings on that deck should be able to be watertight. Indeed if you look at the report, the rest of the deck was.
- 089723645897236 8y agoThe real story here is that the ship was past it's retirement age AND poorly maintained. Any of the series of small events that happened due to the maintenance issues like the scuttle popping open, or the oil sumps not being filled all the way up (these guys were really macho idiots, how expensive is a sump top off really!). The engineers at the NTSB determined that they hit the sweet spot of their engines not working because of the extreme weather and list and unfilled sumps and broken anemometer so they couldn't tell the weather like sailors have been relying on for years. Basically tech is useless if you don't maintain it or replace it or you treat human beings like disposable parts to run your depreciating hulks. The whole world shipping community is running ridiculously old and poorly maintained wrecks sailed by the worlds poorest people for the world's richest assholes. How's that for a class struggle?
- 089723645897236 8y agoI suspect that human driven errors like this will lead the shipping industry to transition to autonomy. Through this whole story the autopilot was the only one steering the ship, the humans in the loop were responsible for plotting and course setting. Obviously this is a bad idea. It's not hard to imagine an expert software system that could have done a better job with this situation, especially in processing the text based weather data coming over the C-sat. Apparently some Norweigans agree with me and are doing exactly this. I suspect this will become the future norm once the bugs are ironed out. https://www.km.kongsberg.com/ks/web/nokbg0238.nsf/AllWeb/0CBA6362C268ED02C1258264002EB6C4?OpenDocument https://www.km.kongsberg.com/ks/web/nokbg0238.nsf/AllWeb/0CB...
- NKosmatos 8y agoVery nice and intense read, couldn’t stop till the end. I’m sure it would make a great movie. Pity for the people on board.
- pontifier 8y agoOk, this article was the last straw. I've disabled javascript. It was impossible to read this article without it scrolling every few seconds for some ad script.