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The Worst U.S. Maritime Disaster in Decades

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Re: The Worst U.S. Maritime Disaster in Decades

#61

Post by forapurpose »

jacquesm wrote: post #57
forapurpose wrote: post #56

Earlier quoted context omitted.

Yes, 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 in…

Not that it will comfort you much but you are hardly alone in this. Bad backups, logging on the same servers as where access takes place and single points of failure in personnel are some of the most frequently occurring things I come across in my 'day job'.

Thanks, and I know it well; that was an early lesson. Backups in particular are an amazing cesspool of problems for something so conceptually simple.

Re: The Worst U.S. Maritime Disaster in Decades

#62

Post by jacquesm »

forapurpose wrote: post #61
jacquesm wrote: post #57

Earlier quoted context omitted.

Not that it will comfort you much but you are hardly alone in this. Bad backups, logging on the same servers as where access takes place and single points of failure in personnel are some of the most frequently occurring things I come across in my 'day job'.

Thanks, and I know it well; that was an early lesson. Backups in particular are an amazing cesspool of problems for something so conceptually simple.

That's the thing that always bugs me, the vast majority of the items that I end up with on the todo list after a review would cost $0 or very little to get right.

Super frustrating. And you can't even rely on things staying fixed either, you have to review periodically or it will be back to square #1 within the year.

Re: The Worst U.S. Maritime Disaster in Decades

#63

Post by jfaat »

BuffaloBagel wrote: post #53

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.

Cost, most likely

Re: The Worst U.S. Maritime Disaster in Decades

#64

Post by HeyLaughingBoy »

V2hLe0ThslzRaV2 wrote: post #8

Does 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 D…

If you want to die on a ship, it's simple: step over the side on a dark night. No one will ever know what happened. No need for complex plans involving weather, your crew, machinery failure, etc.

Re: The Worst U.S. Maritime Disaster in Decades

#65

Post by YeGoblynQueenne »

Bridge transcript, addenda and errata:

Voyage Data Recorder

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...

Addendum to Voyage Data Recorder

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...

Re: The Worst U.S. Maritime Disaster in Decades

#66

Post by forapurpose »

jacquesm wrote: post #62
forapurpose wrote: post #61

Earlier quoted context omitted.

Thanks, and I know it well; that was an early lesson. Backups in particular are an amazing cesspool of problems for something so conceptually simple.

That's the thing that always bugs me, the vast majority of the items that I end up with on the todo list after a review would cost $0 or very little to get right. Super frustrating. And you can't even rely on things staying fixed either, you have to review periodically or it will be back to square #1 within the year.

> the vast majority of the items that I end up with on the todo list after a review would cost $0 or very little to get right

Agreed, and I drive people crazy with my focus on those things. Thorough design and implementation (including testing) up front cost far less than correcting problems later, and they don't add the enormous cost of downtime and other failures.

But ... I've found that human beings, even serious professionals, have a capacity limit for details, and it's not very high; and if it's for an over-the-horizon risk, attention is very limited. That is my biggest constraint, editing down the details, organizing them, automating them, and making trade-offs to reduce them to a point where others don't throw up their hands. Also, it's hard to get the budget for that up front investment in what looks to others like obsessiveness (it's not; it's carefully considered ROI).

So when you show up for your review (I don't know exactly what you do, but I have an impression), 1,000 details might have been addressed but 50 overlooked. or 1,050 details might have been implemented but there was no capacity for the next 100 - resources ran out, something else came up, etc.

So I can see it both ways.

Re: The Worst U.S. Maritime Disaster in Decades

#67

Post by tomn »

dwighttk wrote: post #19

>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 w…

captain: "Can i play it safe on the way back?"

boss: "Yes, authorized."

NTSB: "What do you mean authorized? It's not your decision. Did the captain ask you if he could go the safe way on the way out?"

Re: The Worst U.S. Maritime Disaster in Decades

#68

Post by oh_sigh »

sdhgaiojfsa wrote: post #11

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.

That's a pretty bad take away - no one wanted to drive trough the hurricane. The captain thought he was further away from the storm than he was, perhaps because of his use of an outdated weather feed.

A better take away might be, for important decisions, you should deeply understand the data(and importantly, it's limitations) you are using to make the decision.

Re: The Worst U.S. Maritime Disaster in Decades

#69

Post by jacquesm »

forapurpose wrote: post #66
jacquesm wrote: post #62

Earlier quoted context omitted.

That's the thing that always bugs me, the vast majority of the items that I end up with on the todo list after a review would cost $0 or very little to get right. Super frustrating. And you can't even rely on things staying fixed either, you have to review periodically or it will be back to square #1 within the year.

> the vast majority of the items that I end up with on the todo list after a review would cost $0 or very little to get right Agreed, and I drive people crazy with my focus on those things. Thorough design and implementation (including testing) up front cost far less than correcting problems later, and they don't add the enormous cost of downtime and other failures. But ... I've found that human beings, even serious…

Good stuff, thank you, I can see there might be some way to get a process in place to avoid these relapses.

Re: The Worst U.S. Maritime Disaster in Decades

#70

Post by user5994461 »

bklyn11201 wrote: post #29
sdhgaiojfsa wrote: post #11

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.

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...

Another conclusion is to never be in a business that tries to save pennies by not subscribing to life critical data.
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