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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

#71

Post by mjn »

jfaat wrote: post #63
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

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.

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

#72

Post by dwighttk »

tomn wrote: post #67
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?"

I guess I still don't quite understand the importance of "authorized" since the captain wrote:

>Question I would like to transit the Old Bahama Channel on our return northbound leg

He was clearly asking, not informing.

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

#73

Post by SlowBro »

badloginagain wrote: post #60
gregschlom wrote: post #51

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…

Also note that B.V.S did appear to have a 'Hourly Update' feature that did not appear to be subscribed to. It's also important to realize that the captain was confident with the plan- except the storm in question was abnormal. That's an important fact to consider, as it throws the mariners heuristics off deciding how much more attention to pay.

> Also note that B.V.S did appear to have a 'Hourly Update' feature that did not appear to be subscribed to.

From the article, "The Coast Guard report also noted that “El Faro crew did not take advantage of B.V.S.’s tropical update feature,” which would have provided hourly updates."

So hourly updates apparently were available even if not subscribed to.

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

#74

Post by Analemma_ »

doughj3 wrote: post #23

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

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.

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

#75

Post by tomn »

dwighttk wrote: post #72
tomn wrote: post #67

Earlier quoted context omitted.

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?"

I guess I still don't quite understand the importance of "authorized" since the captain wrote: >Question I would like to transit the Old Bahama Channel on our return northbound leg He was clearly asking, not informing.

That could be interpreted as "will it cause a schedule problem", or "is there another option I should consider" or "might this make it worse". Ultimately he never actually asks a question, just says what he's thinking about doing. To me it reads like the captain is keeping his superiors in the loop, but still has controll.

The problem with the response is that it has clearly been treated as a request ("diversion request heads up through Old Bahama Channel understood and authorized") that could have been denied.

It's obviously not an admission of guilt, but a red flag that's worth investigating.

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

#76

Post by Natsu »

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'.

Been there, done that.

I recently helped a company big enough that everyone here would recognize the name fix a lot of items around monitoring and logging after finding they were running an important production system in such a manner as to be essentially flying blind. Yeah, those fatal errors in the logs just might be important...

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

#77

Post by anonoholic »

r00fus wrote: post #55
gregschlom wrote: post #51

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…

Is 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).

> Is that really a UI issue?

More of a UX issue. The worst possible kind.

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

#78

Post by dwighttk »

tomn wrote: post #75
dwighttk wrote: post #72

Earlier quoted context omitted.

I guess I still don't quite understand the importance of "authorized" since the captain wrote: >Question I would like to transit the Old Bahama Channel on our return northbound leg He was clearly asking, not informing.

That could be interpreted as "will it cause a schedule problem", or "is there another option I should consider" or "might this make it worse". Ultimately he never actually asks a question, just says what he's thinking about doing. To me it reads like the captain is keeping his superiors in the loop, but still has controll. The problem with the response is that it has clearly been treated as a request ("diversion requ…

thanks... I'm finally getting all the bubbles in that thought smoothed down.

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

#79

Post by walshemj »

mannykannot wrote: post #17
jtwaleson wrote: post #10

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.

A 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-sh...

Its probably including fishing which has I would imagine a much higher rate than crews on a cruise liner.

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

#80

Post by phlakaton »

dwighttk wrote: post #34
aniro wrote: post #22

Earlier quoted context omitted.

>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.

oh, 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.

Right--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.

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