
The Worst U.S. Maritime Disaster in Decades - ryanfox
https://www.vanityfair.com/news/2018/04/inside-el-faro-the-worst-us-maritime-disaster-in-decades
======
gregschlom
I 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.

~~~
crooked-v
The bit you skipped:

> He went down to his stateroom after his conversation with Schultz, and when
> he returned to the bridge he said, “All right, I just sent up the latest
> weather. Let us clear everything off the chart table with the exception of
> the charts.” Schultz opened the B.V.S. program. As it happened, according to
> the N.T.S.B. report, because of a software glitch, the map that appeared was
> the very same map that had come in with the previous download, six hours
> earlier. The raw data on which it was based was at least 12 hours old.

It sounds like it wouldn't actually have helped if the captain had the per-
hour update, because this undetailed software glitch meant the device wasn't
showing the updated maps anyway.

The apparent moral of that part of the story is that the B.V.S. charts are
past useless and into actively harmful territory, since they may not just be
old but instead actively incorrect.

~~~
degenerate
Sounds like the mapping software should put a big red timestamp in the middle
of the map if the current data is over 1 hour old.

It's unfortunate when programmers overlook something this big.

------
YeGoblynQueenne
Bridge transcript, addenda and errata:

Voyage Data Recorder

[https://dms.ntsb.gov/pubdms/search/document.cfm?docID=447547...](https://dms.ntsb.gov/pubdms/search/document.cfm?docID=447547&docketID=58116&mkey=92109)

Errata to Voyage Data Recorder

[https://dms.ntsb.gov/pubdms/search/document.cfm?docID=455021...](https://dms.ntsb.gov/pubdms/search/document.cfm?docID=455021&docketID=58116&mkey=92109)

Addendum to Voyage Data Recorder

[https://dms.ntsb.gov/pubdms/search/document.cfm?docID=455022...](https://dms.ntsb.gov/pubdms/search/document.cfm?docID=455022&docketID=58116&mkey=92109)

Attachment 1 to Addendum to Voyage Data Recorder

[https://dms.ntsb.gov/pubdms/search/document.cfm?docID=455023...](https://dms.ntsb.gov/pubdms/search/document.cfm?docID=455023&docketID=58116&mkey=92109)

~~~
dmix
Is the audio available from the deck?

~~~
YeGoblynQueenne
I didn't see it anywhere.

Oh man. That transcript was the single worst thing I ever read in my whole
life.

------
clon
> 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.

~~~
korethr
One of my takeaways from the article is that the captain's confidence and
willingness to do the right thing had been shaken after he'd been burned the
last time he'd refused unsafe orders. I'm wondering if the 1st officer
similarly faced bad consequences for doing the right thing and taking command
-- mutiny charges are still a thing, aren't they?

~~~
jacquesm
There's a movie that reviews that situation in a navy (nuclear submarine)
context, it's called 'Crimson Tide'.

~~~
leesalminen
Not sure why you’re being downvoted, Jacques. We’ve been in a couple spats
here but I’ve always respected your thoughts and opinion. Have (yet another)
upvote :).

~~~
jacquesm
I suspect my comments in the thread about the Google shooting gained me a
fresh batch of enemies.

~~~
saturationPoint
If you look at the numbers for this site, these days, HN is too popular for
it's own good, and it's getting really noisy.

On the front page right now, there are lots of garbage articles, with 500+
upvotes and comments, and any one of them handily enables new downvoters.

Way more people can downvote now, than ever before, and users relish new
power. Having a respectful honor system, and some voting ring detection is
great, but the truth is, there are a lot more shitty people on this site. What
to do about that?

~~~
jessaustin
I'm not saying you're wrong, but would you mind posting that from your non-
greenbean account? I won't downvote you! It's just fake internet points
anyway; why worry? I get downvoted every day I post. ( _Not_ every _item_ I
post.) Sometimes there is a lesson to be learned, sometimes there isn't.

------
Luc
I 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.

~~~
SeanBoocock
A great example is his treatment of Air France 447:
[https://www.vanityfair.com/news/business/2014/10/air-
france-...](https://www.vanityfair.com/news/business/2014/10/air-france-
flight-447-crash)

~~~
Stratoscope
Oh 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)

~~~
dreamcompiler
Yep. S&R is one of the best nonfiction technical books ever, even if you have
no particular interest in becoming a pilot.

------
nradov
The 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/)

------
sdhgaiojfsa
My 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
Another 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...](http://www.stormgeo.com/solutions/shipping/on-board-services/bvs-
routing/)

~~~
yread
Another important part are the flashy graphics. People always trust you more
with flashy graphics against a list of coordinates

~~~
hinkley
As 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.

------
chrisweekly
1\. 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
As to point #2: [https://www.fleetmon.com/maritime-
news/?category=incidents](https://www.fleetmon.com/maritime-
news/?category=incidents) has a sobering list.

------
cesarb
NTSB report:
[https://www.ntsb.gov/investigations/AccidentReports/Reports/...](https://www.ntsb.gov/investigations/AccidentReports/Reports/MAR1701.pdf)

~~~
dz0ny
It 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)

~~~
fwip
23 nanometers off, dang. If they'd only had a slightly wider field of view,
they could have found those poor people. :(

~~~
bjt2n3904
Perhaps 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.

~~~
jzwinck
Nm is Newton meters. You're looking for NM (Nautical Miles). Common mistake.

Similarly, kt means knots as in speed, but the very same kt also means
kilotonnes as in dynamite.

------
jtwaleson
The 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.

~~~
lainga
Fermi estimate, about 120-180 sinkings a year * 30 crewmembers/ship * 0.75
chance of dying (I'm guessing some sink in port or are evacuated?) = 2700
deaths / year.

~~~
chrisseaton
Why do you think the chance of dying on a sinking ship would be so incredibly
high?

0.75 chance of dying is what you had on the Titanic!

Your number has no relation to reality at all.

[https://en.m.wikipedia.org/wiki/List_of_shipwrecks_in_2017](https://en.m.wikipedia.org/wiki/List_of_shipwrecks_in_2017)

~~~
lainga
That is why I qualified it as a Fermi estimate. I was guessing randomly.

~~~
fapjacks
Fermi estimate or guessing randomly: Pick one. They are mutually exclusive.

~~~
lainga
Good point. I was guessing randomly _with justification_. If I had guessed
that 0.001% or 1000% of all sunk sailors died it wouldn't be a Fermi estimate.

------
doughj3
For anyone interested in stories like these, I highly recommend "Normal
Accidents" by Charles Perrow - there's an entire chapter on maritime
accidents.

~~~
Analemma_
Seconded, 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
There'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.

------
BuffaloBagel
Wonder 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
Cost, most likely

~~~
mjn
I 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.

------
leeter
What 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
well 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
True, 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.

------
dwighttk
>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.

~~~
bklyn11201
The 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.

~~~
macintux
Seems safe to assume those two tugboats cost a hell of a lot less than this
accident and the wrongful death suits, not to mention the unnecessary
fatalities.

~~~
clort
Yeah, the trouble is though.. the tugboats got paid for and the steering gear
didn't fail as it wasn't used.

Same here, he goes a different way and costs the company money and all of a
sudden its not comparing the cost of the diversion with the cost of the loss
of the ship and crew, its only comparing it to a safe but tense voyage.

------
Nrbelex
See also an in-depth report from the AP:
[https://apnews.com/9d5904f83f6a4cf784828107fa7d038d](https://apnews.com/9d5904f83f6a4cf784828107fa7d038d)

------
foobarbazetc
What’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.

~~~
boomka
The 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.

------
brightball
That was hard to read.

~~~
istorical
Lump in throat - but can't stop until the end - reading.

~~~
Nexxxeh
>Hamm said, “You gonna leave me?”

>Davidson answered firmly, “I’m not leaving you. Let’s go.”

Fuck me, I can't even imagine what that must be like. And I'm grateful for
that.

------
Baeocystin
Damn. That was intense. Thanks for posting this.

------
089723645897236
I 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/0CB...](https://www.km.kongsberg.com/ks/web/nokbg0238.nsf/AllWeb/0CBA6362C268ED02C1258264002EB6C4?OpenDocument)

------
deadwing0
Anyone 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.

------
NKosmatos
Very 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
Ok, 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.

------
myrandomcomment
Wow. I know it is long, but read it if you have not. It’s very....human.

