[Peetwo]

NTSB v ATCB: A point of comparison.

From Independent Australia & the Oz: ref - PelAir MKII post #99

James said:

"They have lost their nerve — they are not courageous. They are scathing when they criticise me. Everyone [else] has a let-off and an excuse. It is a failure in process and a failure in result. If the ATSB and CASA were doing their job and everything was done appropriately and transparently, you don't have a Senate Inquiry, you don't have Canadian investigators roped in and you don't have a safety review."

Although not an AAI, the following NTSB news presser (& executive summary) for the release of a high profile marine accident investigation IMO perfectly highlights the difference between a truly independent transport safety investigator, versus our version of a politically and commercially captured imitation of a TSI...

NTSB News Release

National Transportation Safety Board Office of Public Affairs

Captain’s Decisions, Shipping Company’s Poor Safety Oversight Led to Sinking, NTSB Says
12/12/2017

Page Content
WASHINGTON (Dec. 12, 2017) — The deadliest shipping disaster involving a U.S.-flagged vessel in more than 30 years was caused by a captain’s failure to avoid sailing into a hurricane despite numerous opportunities to route a course away from hazardous weather, the National Transportation Safety Board announced during a public meeting Tuesday.

The 790-foot, cargo vessel, S.S. El Faro, en route from Jacksonville, Florida, to San Juan, Puerto Rico, sank Oct. 1, 2015, in the Atlantic Ocean during Hurricane Joaquin, taking the lives of all 33 aboard. 

“We may never understand why the captain failed to heed his crew’s concerns about sailing into the path of a hurricane, or why he refused to chart a safer course away from such dangerous weather,” said NTSB Chairman Robert L. Sumwalt.  “But we know all too well the devastating consequences of those decisions.”

NTSB investigators worked closely with the U.S. military and federal- and private-sector partners to locate the wreckage, photo- and video-document the ship and related debris field, and recover the El Faro’s voyage data recorder from more than 15,000 feet under the surface of the sea. 
 

 

 

El Faro at sea viewed from stern (Photo by William Hoey)

Color-enhanced satellite imagery of Hurricane Joaquin taken close to the accident time.
El Faro’s track is identified by the green line.

 

The ship departed Florida Sept. 29, 2015, and had a range of navigation options that would have allowed it to steer clear of the storm that later became a Category 4 hurricane.  The captain, consulting outdated weather forecasts and ignoring the suggestions of his bridge officers to take the ship farther south and away from the storm, ordered a course that intersected with the path of a hurricane that pounded the ship with 35-foot seas and 100 mph winds.

As the ship sailed into the outer bands of the storm, about five hours prior to the sinking, its speed decreased and it began to list to starboard due to severe wind and seas.  In the last few hours of the voyage, the crew struggled to deal with a cascading series of events, any one of which could have endangered the ship on its own.
 
Seawater entered the ship through cargo loading and other openings on a partially enclosed deck in the ship’s hull, pooled on the starboard side and poured through an open hatch into a cargo hold.  The hold began to fill with seawater, and automobiles in the hold broke free of lashings and likely ruptured a fire main pipe that could have allowed thousands of gallons of seawater per minute into the ship – faster than could be removed by bilge pumps. 

About 90 minutes before the sinking the listing ship lost its propulsion and was unable to maneuver, leaving it at the mercy of the sea.  Although the captain ordered the crew to abandon ship when the sinking was imminent, the crew’s chances of survival were significantly reduced because El Faro was equipped with life rafts and open uncovered lifeboats, which met requirements but were ineffective in hurricane conditions.

The NTSB also said that the poor oversight and inadequate safety management system of the ship’s operator, TOTE, contributed to the sinking. 

“Although El Faro and its crew should never have found themselves in such treacherous weather, that ship was not destined to sink,” said Sumwalt.  “If the crew had more information about the status of the hatches, how to best manage the flooding situation, and the ship’s vulnerabilities when in a sustained list, the accident might have been prevented.”

As a result of the 26-month long investigation, the NTSB made 29 recommendations to the U.S. Coast Guard, two to the Federal Communications Commission, one to the National Ocean and Atmospheric Administration, nine to the International Association of Classification Societies, one to the American Bureau of Shipping, one to Furuno Electric Company and 10 to TOTE Services.

The complete accident report will be available in several weeks.  The executive summary, including the findings, probable cause and safety recommendations is available at https://go.usa.gov/xnRAn.

Additional information related to this investigation, including news releases, photographs, videos, and a link to the accident docket containing more than 30,000 pages of factual material, is available on the El Faro accident investigation page at http://go.usa.gov/xnRTW.

Now although this is an extremely high profile and complex marine accident investigation, it is worth noting that it took 2 years, 2 months to complete. It is also worth comparing the chronologically recorded investigation webpage - see here complete with the preliminary report and regular media updates - then review the latest (& presumably last) ATSB VH-NGA (re-)investigation webpage: https://www.atsb.gov.au/publications/inv...-2009-072/  

Anyone else spot the difference...



MTF...P2