
Sinking of the US Cargo Vessel El Faro: Illustrated digest [pdf] - curtis
https://www.ntsb.gov/investigations/AccidentReports/Reports/SPC1801.pdf
======
markonen
The recent Vanity Fair story about this tragedy is absolutely riveting, even
though you know exactly what is going to happen:
[https://www.vanityfair.com/news/2018/04/inside-el-faro-
the-w...](https://www.vanityfair.com/news/2018/04/inside-el-faro-the-worst-us-
maritime-disaster-in-decades)

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dmckeon
All else aside, the UI/UX issues here are heart-wrenching. The captain
preferred a graphic representation, even though it was 6 to 12 hours out of
date, over a more current text-based report/forecast. On two occasions,
warnings or new data arrived just a few minutes after a report/forecast was
viewed. Crew members watching the Weather Channel had more current/accurate
information than the captain.

I can easily see how a graphic might be preferred over text, regardless of
data currency, and especially during the 95%+ times of smooth sailing, but to
see how this situation turned out is troubling.

~~~
vpribish
I'd like to see the actual BVS UI. Does it indicate how old the data is or
just the timestamp the report was generated? This is a detail that bites lots
of reports in business.

~~~
marvin
Maybe the people who develop the software don't talk to the end users, or see
how they use the software. That would be a classic example of development
process gone wrong. Are they, or people sufficiently near to them on the
organizational chart, aware that life-or-death decisions are made on the basis
of their software? (I'd certainly hope so, plotting weather data definitely
qualifies).

I'm only conjecturing here; there's no reason to conclude based on the
available information that there is a problem here. But it would be a pretty
typical situation in an organization that believes software is something you
call up a subcontractor to bolt on -- most places are still run like that,
although the culture is slowly changing.

~~~
AnonTemp123
For obvious reasons can't comment too much, but it does, they did, and makes
quite clear that it's not for navigational purposes.

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marvin
Interesting, thanks for the tidbit of inside information :)

You'll have to pardon me for asking a stupid question, though -- what other
purpose than navigation would a maritime weather report/forecast reasonably
have? This seems to me at first look as a protection against liability, rather
than an actual clarification of the intended usage of the product.

I guess I could imagine a use case such as operations planning, e.g. "will we
likely be able to perform work on deck tomorrow?", where the stakes are lower,
but I imagine the potential for misunderstanding and incorrect usage of such a
service would be dangerously big.

~~~
AnonTemp123
You're welcome.

It's for optimization of future routes -- how do I get from point A to point B
while keeping some weather parameters in acceptable range, burning less fuel,
and getting there on schedule. And yes, trying not to drive right into a
storm. Not quite for trying to maneuver out after you have already driven into
one.

Of course you can also look at it and figure out of cleaning the deck is a
good idea or not.

I probably shouldn't comment further, but NTSB's full report is at
[https://www.ntsb.gov/investigations/AccidentReports/Reports/...](https://www.ntsb.gov/investigations/AccidentReports/Reports/MAR1701.pdf)
and they did not seem to find it too confusing.

~~~
marvin
Thank you :)

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ocdtrekkie
Definitely impressed by the design work that went into this report. I'd be
super curious to hear from people who design these sorts of communications.
Usually we think of a well designed pamphlet for marketing purposes, but clear
informative presentation here well exceeds what I've traditionally expected
from a government report.

~~~
njharman
It is marketing.

1) they want all to "buy into" their proposed changes. 2) they want all to
know how important their work is and why they should remain in the budget.

~~~
tlb
That level of cynicism may apply to some government departments, but agencies
like the NTSB are much more grounded.

When there's a bad accident on a ship that was more-or-less following
procedures, owners and captains of ships really want to know what went wrong
and why, so they can avoid it themselves. This is the sort of document that
captains will read and discuss with their crew, not all of whom are highly
literate in English, so it needs to be accessible and clear. It seems to me
that the NTSB did good work here.

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curtis
Something that I'd missed in previous articles about the El Faro sinking:

> _Then, at 0554 , the captain ordered a turn to port to get the wind on the
> ship’s starboard side, generating a port list. A few minutes later, El Faro
> lost propulsion_

\---

> _Log books indicated no more than 26 inches of oil in the sump in the months
> before the accident ( a ). With this oil level, the bellmouth would not take
> in air (lose suction) with an 18-degree list to starboard ( b ), but would
> lose suction with an equivalent list to port ( c )._

They had other serious problems, but loosing propulsion in heavy seas is very
serious indeed.

~~~
sjburt
It's interesting that the low oil pressure cutoff (designed to prevent engine
damage from running without lubrication) is amongst the things that ultimately
doomed the vessel.

~~~
princekolt
Or the engine would have died anyway from running with no oil for another
hour. Considering they were in the middle of the storm and that the captain
rejected giving up until the very last moment, I don't think it would have
made a difference.

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mathgenius
I'm curious how much this is about "many small and unlikely failures leading
to disaster", versus "they sailed into a big storm and were doomed". The usual
narrative with complex engineering disasters is the former. I'm wondering, for
example, if everything else was going well with the ship, could they have
survived such a close encounter with such a big storm? Or, if the engine was
kept online, would that have changed anything? It seems to me that this
situation went far beyond survivability, but it's hard to tell from the NTSB
report.

~~~
rdiddly
It seems like both... don't sail into a hurricane and there's no problem,
right? But even their sailing into it was an interaction of many factors --
the captain's insistence, predicated on preferring the graphically vivid but
outdated weather maps, and on disregarding the opinions of his officers, and
on each of them independently failing to be sufficiently assertive (or even
convinced of the danger themselves) to change his mind.

There's also the broken anemometer, but I'm tempted to discount that, because
it was obvious the wind was from port, indicating (in any counter-clockwise-
rotating storm, i.e. any cyclone in the northern hemisphere) you are headed
right into it. Winds should have been from astern if you were trying to cross
in front of it. When you're convinced of something, sometimes you can stare
right at contrary evidence and disregard it. But who knows, maybe having an
accurate wind reading would've jogged some brain cells.

If the engine was kept running as you say, that might have helped them, but
_only_ if they had used it to turn and get the hell out of there. If the
captain insists on using it to continue driving straight into a hurricane, it
just makes things worse. And then of course there's all the water they took
on, limiting their getaway speed so to speak. In a certain way it seems like
the point of no return was the rupture of the fire water inlet. No telling
what the ship could've withstood if they had secured the load better and
secured the hatches better. Unfortunately all you get with this kind of
hindsight is all the things that went wrong, not necessarily what would've had
to go right.

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wildrhythms
This was an incredibly fascinating and shockingly well designed doc. Excellent
work from the NTSB putting this together.

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mcguire
Anyone know if the BVS data has a timestamp?

An excellent and very readable document, by the way.

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lb1lf
-It does; however, the timestamp only shows when the report was compiled; it does not show when the data the report is based on were collected.

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princekolt
As someone who builds software that generates exportable reports, I can say
this is one of the cardinal sins of data visualization. Another one is
relative timestamps akin to "just now".

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Treblemaker
I know, right?
[https://pasteboard.co/Hn35e51.png](https://pasteboard.co/Hn35e51.png)

