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.
> 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.
It's unfortunate when programmers overlook something this big.
(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 indeed checked the logs daily and they were fine. She was right: She was seeing the log from the last backup, unchanged every day. My fault entirely, not hers: We should have anticipated the date problem, and we should have utilized someone technically literate enough to understand what they were reading - in this case, someone who would recognize an 'obvious' problem such as the numbers of files and bytes not changing. And we should have tested our backups more often, but that old lesson almost isn't worth mentioning.)
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.
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.
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).
More of a UX issue. The worst possible kind.
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...
Oh man. That transcript was the single worst thing I ever read in my whole life.
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.
The recommendations for the crew to "issue a direct command or to use a crew obligation statement — a statement in which the subordinate obligates the senior crewmember as part of the navigational team by using language such as 'we should' or 'our route'" is excellent. People who need to "manage up" at their jobs can start doing this today.
The root cause was a captain who mistakenly reacted off of 12 hour old data and ignored another source of data that contradicted it. Pretty surprising given the lengths the article goes through to impress upon the reader how "safety conscious" he was.
This is just one serious problem in the maritime industry that I have first-hand knowledge of.
I loved sailing, but I don't do it any more because it's not the work that's dangerous, it's the other people.
All his articles and books seem to be movie-worthy. I'm not entirely convinced reality is that exciting, though.
The reality in this case was far, far more exciting than you ever want. If anything, the captain had a preternaturally professional calm.
> ship’s anemometer was in disrepair and had been for weeks
Can't measure wind; the co. didn't subscribe to hourly updates; a "software glitch" gave old reports.
And honestly, experienced Merchant officers have seen so much shit, it's hard to get them rattled.
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.
"In the cockpit, the situation was off the scale of test flights. After Dubois arrived, the stall warning temporarily stopped, essentially because the angle of attack was so extreme that the system rejected the data as invalid. This led to a perverse reversal that lasted nearly to the impact: each time Bonin happened to lower the nose, rendering the angle of attack marginally less severe, the stall warning sounded again—a negative reinforcement that may have locked him into his pattern of pitching up, assuming he was hearing the stall warning at all."
They must have been so confused and frightened.
He writes in a gripping manner and normally seems to have done pretty thorough background research, as well as personal experience.
http://www.stormgeo.com/solutions/shipping/on-board-services...
What they needed was hourly updates, which they had from the other service they subscribed to, which was ignored by the captain. Despite the staff being fully aware.
And the captain and staff should always be reading weather data from two sources anyway, for redundancy and accuracy.
These guys had plenty of information but over-relied on one which was 6-12hrs out-of-date at the worst time, which no indication it was old data.
These are solvable problems that have little to do with tiered pricing or a cheapness on part of the company. Both by the above redundancy and the weather company dating their data, and fixing software bugs for such critical software.
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.
Very apt also for the Air France 447 crash this author wrote about.
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."
It's the key reason I don't find commercial marine nuclear propulsion viable.
The paper does mention that other estimates have reached both considerably higher and considerably lower totals (they quote one author who estimated 13,000/yr in the 1980s!). It's hard to get good numbers because the worst safety records appear to be among flag-of-convenience nations who also have the worst reporting and insurance practices, so a large portion of total fatalities (probably) come from the places with the highest uncertainties. But even among rich nations they did still find it a comparatively dangerous occupation: it's safer to be a Danish-flagged seafarer than most other flags, but still >10x the fatality rate compared to having a job on land in Denmark.
0.75 chance of dying is what you had on the Titanic!
Your number has no relation to reality at all.
https://www.newscientist.com/article/mg23731623-300-ghost-sh...
Is there a "sequel" to Normal Accidents about software? Because I'd buy that in a heartbeat.
Ex-Goggler Yonatan Zunger has had some really good recent essays at, variously, Medium, Twitter, the Boston Globe, and Google+ (for which he was chief architect, and despite its general lack of widespread success, I consider his contributions and lessons-learned experience quite positively).
And he's a fan of Perrow.
Bruce Schneier's work is somewhat more focussed on crypto and security, but covers much this ground, especially later works.
Shoshana Zuboff also addresses social impacts of computers and data systems in her work.
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.
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?"
>Question I would like to transit the Old Bahama Channel on our return northbound leg
He was clearly asking, not informing.
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.
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.
Some don't pull back because of cowardice.
The rest keep on going because of the sense of adventure. It makes you feel alive.
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...
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.
