The sinking of the container ship ‘El Faro’ in October 2015, claiming the title of one of the biggest marine tragedies in the recent history of US, was largely attributed to the Captain’s wrong assessment of the conditions. Anastasios Chrysikopoulos, Chief Officer at Maran Dry Management Inc. analyzed the casualty focusing on the Captain’s actions which identified human error as the key lesson to be learned from the El Faro loss.
Introduction
On October 1 2015, El Faro, a United States 790-foot liner container ship operating on a weekly basis between Jacksonville, Florida and San Juan, Puerto Rico sailed right into the center of a category 4 hurricane (Joaquin) and sank. Although El Faro was equipped with the latest weather tracking systems, which provided updated information about the position and expected course of the hurricane, its experienced 53 years old Captain decided not to change the routine route to San Juan, Puerto Rico, and continue as usual putting the vessel in a very close proximity with the hurricane, a decision which led to the loss of the ship and its crew (USCG, 2015). Through the conversations and data obtained by the vessel’s Voyage Data Recorder (VDR), it is obvious that the Master was informed several times by his crew and the weather information systems about the adverse weather and still, he did not alter the vessel’s route.
Scope
The causes of the accident include human and technical errors, but as in most cases, the human element was the most significant contributing factor. Although the errors of the captain and crew are obvious, the factors that contributed to making such errors are more difficult to identify as they are interrelated with the Human Element. The scope of this paper is to identify and analyze issues that affected the Captain’s and crew decision-making process in connection with the Human Element, to understand how it can better be facilitated.
Methodology
As the Ship’s Captain is the main actor of the accident, due to the fact that he had the ultimate responsibility and authority for the decisions carried out during the voyage, this paper will focus on his perspective and how the interactions with the other crew, the company, and the working environment affected his decisions.
Captain’s decision not to take a safer route
According to National Transportation Safety Board “the probable cause of the sinking of 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” (NTSB, 2017, p. 8). Captain’s decision not to take a safer route was influenced by various factors and processes related to the Human Element. These factors/processes include:
- Assessing the situation
- Assessing the risks
- Team Work
- Communication
- Physical and Mental Factors
- Working Environment Factors
Although these factors will be analyzed separately, it is of much importance to understand that they are closely related and influence each other and all of them contribute in less or greater extent into making a decision.
Assessing the situation
How people interpret the world around them varies on their personal needs, self –concept, past experiences, sharing goals, and the practicalities of the situation (Dik Gregory, 2010). As a result, something obvious to one person might not be understandable to another. El Faro’s case is a great example to illustrate how different opinions regarding a situation may vary significantly from one person to another. For the reader who is distant from the case, it is obvious that the situation of an evolving hurricane close to the vessels route is considered a big threat. Thus it must be avoided at all costs. For the Captain obviously that wasn’t the situation.
- Personal needs;
The captain recently before the last voyage of El Faro had requested for a promotion to the newer company’s vessels. In his view, taking a longer, costlier route would dissatisfy his supervisors, hence minimize the probability for that much-desired promotion. The captain had doubts regarding operational costs even with the minor alteration he had made.
- Past experiences;
During his previous contract with another shipping company, he was fired for hiring additional tug boats for maneuvering the vessel (USCG, 2015).
- Self-Concept;
His many years of experience in Alaska’s seas contributed to his overconfidence regarding adverse weather situations. Additionally, being fired for using additional tugs made him question his ability to balance among efficiency and thoroughness, a task that a modern seafarer is constantly engaged.
- Shared Goals;
Having a defined and supported common goal (by company procedures) with the company would help the captain to prioritize efficiency and thoroughness. During the Erika and Danny tropical systems (August 2015), the company sent a Safety alert regarding Hurricane Danny and the Master supported by the Alert, took the safe ‘’Old Bahamas route’’. During the accident voyage, there wasn’t any Alert at any point from the company which created doubts about the seriousness of the situation.
- Practicalities;
Even though El Faro had plenty means of obtaining weather data (BVS, FAXIMILE, CAT-C, NAVTEX, RADIO) the captain relied exclusively on the BVS system. If he had cross-checked the information obtained from BVS with the other systems he would have noticed the differences, but as long as the information obtained from BVS where practical enough to fulfill his goal (to continue with the normal route), and he thought that the BVS system was reliable (see section –perceived control), he chooses not to use any other source of information.
Assessing the risk
In any decision people make, there is always a level of uncertainty, therefore, a Risk. In the case of El Faro, the captain’s assessment of risk was affected by;
- Perceived Control; The Master overconfidence (see section –self-concept) together with fatigue (see section –physical and mental factors) and the lack of knowledge about some critical equipment on board;
– BVS system limitations (not up to date and information accuracy)
– Boiler system list limitations (offset suction pipe of lube oil would result into losing suction after a 15 degree port list)
Resulted into believing he had adequate control of the situation. - Perceived Value; People tend to evaluate the risks associated with an action in relevance to their ultimate goals. In the case of El Faro’s captain, the risk of maintaining his original route appeared less risky as this action supported his personal need of getting a promotion and no getting fired (see section –personal needs, past experiences, and environmental factors).
- Perceived Familiarity; The task of sailing the vessel from Florida to Puerto Rico was very familiar to the Captain. Using the same weather monitoring system and operating on a weekly basis at the same route with the same vessel created a comfortable zone which it was very difficult to deviate from.
Team Work
On various occasions during her final voyage the El Faro crew members and the shore side management failed to work as a team. More precisely;
- Bridge Resources/Team Management;
Although the 2/M was responsible for the Voyage Plan that it should be discussed with all Navigating Officers, Captain discussed the Voyage Plan only with the C/M who was fatigued (see section –physical and mental factors). By leaving outside of the decision-making process the 2nd and 3rd mate, the Captain failed to create a team spirit and a sense of common goal among his officers. Οn many occasions the officer of the watch did not provide information regarding the weather updates and other issues to the captain or the officer taking the next watch (C/M conversation with sister vessel 03:45 PM, clanking noises heard and flashes observed by the 2/M). Finally, the officer on board never openly questioned the captain’s decisions mostly due to the hierarchical nature of their occupation (USCG, 2015).
- Company Organizational Issues;
The company failed to support the captain in decision making by not providing weather data information and guidance to the vessel. Additionally, even though there were policies for contacting the DPA at any time a crew member deemed to believe necessary, the Satellite phone for calling the DPA was placed in the ship’s bridge and sending an email also required to pass through the captain before forwarded to the office. Such design discourages the crew to contact the DPA as the anonymity of the informer is compromised.
Communication
Even though the Master was informed numerous times about the evolving situation by the 2nd and 3rd mate, at none of these occasions he decided to re-examine the situation. The failure of communication among the bridge team members was affected by;
- Transmitter failure to pass the meaning of the message;
The 2nd and 3rd mate, influenced by the hierarchical system of their occupation (see –working environment factors), used excessive politeness when they were addressing the Captain regarding the situation. Instead of using obligation words like ‘’we have/should to’’ they used words that indicated their concerns and suggestion as hints and preferences_ ‘’I just wanted, you might want to look at the weather report’’ (National Transportation Safety Board, 2017). This failure is related to Bridge Resources Management (see section –team work).
- Receiver Mental model;
The captain’s perception of the situation (see –assessing the situation and risk sections), together with fatigue and stress (see –physical and mental factors), and finally the Working Environment Factors (see –working environment factors), clouded his judgment and as a result by selectively filtered out the information provided to him into his reality and as a result he denied the suggestions of his officers.
Physical and Mental Factors
Fatigue and Stress are closely linked to each other and influence the performance of individuals in many ways;
– Communication
– Concertation
– Carelessness
– Information Processing
– Mood changes
– Hallucinations
– Reasoning
– Task complexity
El Faro’s Captain and crew performance was influenced by the effects of fatigue and stress in many ways.
- Fatigue;
– Working Schedule; El Faro, operating as a liner ship, had a very tight schedule, more precisely, the vessels had every week two ports of call, on Tuesday departure from Jacksonville to San Juan and Friday departure from San Juan to Jacksonville. While at port all deck crew was working on a six hours shift work and in addition to that, the manning levels of the ship required ‘’all hands on deck’’ during berthing and un-berthing operations (IMO, 2001).
– Additional Workload; El Faro was scheduled for dry docking the following month. As a result, the crew had additional work to perform other than the routine maintenance carried out on board.
– Ship Design; Built in 1975, El Faro did not meet the MLC standards regarding living conditions for the crew. It is worth mentioning that even U.S.A is not a party to MLC, there is a voluntary compliance mechanism provided by the USCG that the majority of the parent company (TSI) vessels followed but not El Faro (National Transportation Safety Board, 2017).
– Organizational issues;
1) The company did not supply port mates for assisting the ship crew to fulfill its port responsibilities, a practice that before the voyage accident was followed.
2) The company re-assign the Captain of the vessel shortly after his previous contract had ended (3 weeks), as a result, the captain was not provided with the appropriate recovery time.
3) There were no standard producers regarding shift rotation for the officers on board. The 2/M was assigned the 0000-0400 watch constantly, and as the time of her duty creates the most unusual sleeping patterns, she was probably exposed to fatigue (WMU, 2018).
- Stress;
Most of the sources of stress among seafarers are related to the nature of their work; Workload, Sea Environment, Time away from home, Employment Uncertainty (see –working environment factors section) (Cooper, 2006). In case of El Faro, the Captain was particularly stressed from the demands of his position as master of the vessel, the Company goals to keep up with the tight schedule and meet the deadlines, his career prospects regarding the desirable position on the new company vessels (see –personal needs section) and the preparatory works that had to be done before the dry dock.
Working Environment Factors
The very nature of seafaring occupation created a lot of pressures (physical and mental) to El Faro crew;
| Hierarchy | Profit-oriented ship design and operation |
| Tradition | Social isolation |
| Male dominated | Multi-cultural |
| Financial pressures | Hostile terrain of operation |
| Regulatory pressures | Employment uncertainty |
| Balance between Profit and Safety | Constant Technological Developments |
| Multi-tasking | Increased Workload |
Conclusion
As human element plays a significant role in the Maritime Transport Industry, the study of human factors is of much importance to understand how to facilitate the people working on board. Some of the human attributes like professionalism are hard to train, but such attributes can be guided by company procedures and regulations (IMO, 2018). Well defined and structured company policies and regulations can assist the crew in vital decision-making situations to choose between efficiency and thoroughness. In the El Faro case the crew and particularly the captain’s decisions were influenced by the human element, but if the company had established an appropriate safety culture within the company, some negative influences could have been avoided. The fundamental requirement of Safety Culture is commitment from the top management which is transferred to the lower divisions of the organization.
The views presented hereabove are only those of the author and not necessarily those of SAFETY4SEA and are for information sharing and discussion purposes only.
About Anastasios Chrysikopoulos
Mr. Anastasios Chrysikopoulos is an experienced Chief Officer with a demonstrated history of working in the maritime industry, skilled in Operations Management, Analytical Skills, Maritime Operations, Inspection, and Maritime. Mr. Chrysikopoulos is a former 2nd degree Captain and has graduated from Lloyds Maritime Academy while he is currently on an MSc at World Maritime University.
I had an occasion to witness a bunch of pathologists performing an autopsy to logically derive the most conclusive causation of human fatality. Out of four acclaimed pathologists, all four had a different opinion after the autopsy. The various logical responses and outcome of an identified problem may not be the best solution but it sets a benchmark, a well-judged hypothesis, which eventually becomes a minimalistic guideline and approach. This is called a “learning curve”.
When unsinkable “TITANIC” sank, it gave rise to SOLAS, various oil pollution led to OILPOL and eventually MARPOL, the sinking of MT “PRESTIGE” gave us now what is known as Place of Refuge. But was it all about the fault of Captains in command of the vessel? No, but then we have an image, where we unanimously and legally held the Master’s responsible for various to all incidents.
EL FARO, yes was a tragic loss and an incident which the maritime industry will not be able to forget, and for me, I will hold us all responsible, who can influence the regulations, decisions, procedures and make a backbone. Yes, the Captian onboard had his own negatives, which “He should have done”, yes, we all know “what he should have done” and many thesis and investigations have got their own derivatives and hurried recommendations, but let us always stop firing the gun from the Captain’s shoulder.
As a Master onboard, with what you have, here I am mentioning categorically the “condition of the vessel”, a Master has to run the show. EL FARO’s boiler’s lost lube oil suction with 15 degrees list, jeopardising the vessel’s propulsion. Yes, the Master had made incorrect turns of the vessel. Why was the vessel “grandfathered” in by the authorities for various design limitations and put to sea? Why was the vessel technically so handicapped that “design and safety” had no correlation?
A Master onboard is not a naval arch or a technically sound to know, when the vessel can lose lube oil suction.
It always takes “two to clap”. This was the essence of the ISM Code. Holding Master responsible, yes, agree, but then was it a total failure of ISM Code for responsibilities of shore management for maintenance, routine inspection and technical competence? If yes, then why are we all resonating about the easiest weak link onboard – Master?
Can you document the fact that all the major maritime incidents in the past occurred solely due to a single decisive pillar’s failure – Master?
The human element, risk-based approach and environmental aspects affecting the human performance are the statistically best practices to assist the team in achieving the task with “identified risks”, “identified limitations” and “identified hazards”, which can be mitigated with involving controls and processes to limit the unknowns, called risk variables. The maritime industry has faced numerous documented incidents in past, which has made the industry evolve and much safer, learning from the past. EL FARO is another unfortunate incident, which has added a plethora of engineering, technical, management and ISM failure, it is not only about the Captainin command.