Great stuff Sal. - coming from a risk manager and how the NTSB reports are edited - you have stated clearly a possible issue with human causality - sadly the NTSB editorial process does not get peer reviewed for this and often the logic and accident determination is lost in the engineering ossification . As soon as the vessel left JVF the ballast issue should have been red flagged to the risk company with the LoadCom screaming an issue and never allowed into Brunswick . Your work helps us in a big way and we appreciate everything you do
As you were talking about the report I was screaming to myself…. “The Mate entered the values manually so they could sail and was going to add ballast once at sea”…. You then said the exact same thing. Great job, I do enjoy your videos.
Also aviation background here, but rubbed soldiers with a number of naval architects and understand that righting arm (G. M.) is a function of listing angle, which is directly impacted by rudder input and forward/tangential velocities. When you said "...but went to Jacksonville first because of the hurricane...", I got the same feeling down the back of my neck that I did when talking heads on TV, a former professor of mine included, were speculating what significance a foam strike from the Space Shuttle ullage arm could have had on the shuttle tiles, just as the first images of Columbia debris from news footage in Texas began to air. That is a chilling feeling, and I've only experienced it twice. Today was the third when you mentioned Jacksonville, then Brunswick. I've sailed Jacksonville, I've seen the bridge span there, everybody knows it's a shallow port. But when the likely cause shifted from suspected incompetence to cost savings (i.e., treatment plant maintenance and dumping fees), I didn't scream, but the back of my neck got hot. Falsification of ballast inputs, followed by a lack of controlling speed in the maneuvering lanes with oncoming traffic plus a failure to notify the captain or pilot of the compromised condition of the ship's stability did all this to the people of Brunswick, but most importantly, the inhabitants of St. Simon's Island, and it turns out it was all for cost reductions and potential time savings in light of the added delay the out of order port calls caused. Such a good clarification. Outstanding. My recollection is that the pilot asked for a speed increase in the final turn when the list began, unwittingly thinking the helm was not responding sufficiently. Had he only known, he would have called for less speed and a wider turn to take the Emerald Ace on her starboard side out of alignment with the channel so as to keep the list to a minimum, but of course, it was too late by then--these aren't sports cars. Most likely they were aware of Emerald Ace's proximity and laid on speed to maintain rudder authority and spacing, assuming ship stability and draft were under control. You may not be able to say it outright, but I can--this was criminal neglect, not only on the part of the First Mate, but on the operational procedures of the operating company. With zero checks and balances, no oversight, no reviewing of how the data were entered, this was an accident waiting to happen. Crew Management Resource (CRM) principles, where everyone can note and identify a mistake, would improve the shipping industry. Korean crew with a long cultural history of deferring to--or possibly hiding things from--those in authority is directly responsible for this ecological destruction that did not end with the removal of the last section of ship yesterday. Thank you for your detailed and animated explanation. This truly is the Warren Commission Report of NTSB reports.
@@macblastoff7700 That's the most comprehensive review I've read and I think your analysis is exactly on-point. This was a tragedy that I heard quite a bit about here in BC. Thank you both for your emotional investment into these sorts of things. Like rules in the aviation industry that they say 'are written in blood'; this is a very similar tragedy that I too agree should be bringing criminal charges.
@@wgowshippingTalk to Dan Gryder Probable Cause… aviation safety channel, a bit (no a lot… ) more confrontational and controversial than you but good fun and well intentioned, he’s in Georgia and famously critical of the slow, ineffective and self-satisfied with the NTSB, now led by “Moped Jenny”…
I said this on day one.. They didn't want to pump in Brunswick's brown water.. (Brunswick is a big estuary and is fed by many silted rivers.) and were not In Ballast... I live here... Great report...
you dont consider the that :- - they had to off load ballast to reduce draft (maintain sufficient bottom clearance) for this port when entering - they put more wieght on ( more draft) - they could not put more (the appropiate ammount of) ballast on because they would not have had enough bottom clearance for the port = ie the possibilty that the ship as loaded was not suitable ( too deep draft) for the port I would appriciate your thoughts / comments on this
13:00 This sounds exactly like a Dan Gryder report! Historically, the NTSB has consistently asked the wrong questions, not interviewed relevant people, and ignored eyewitnesses. Great report, subscribed!
Again, sir, your knowledge and experience at sea as a professional deck officer has clearly stated the issues and questions of why this vessel died in the St Simons Sound. There are no clear explanations available from forensic evidence of the vessel’s load and stability computer that was destroyed, why the vessel did not link its realtime engineering status to a remote database for review prior to sailing and why the deck officers were not thoroughly interrogated by USCG before fleeing back to S Korea. Many unanswered questions like these just add to the frustration and anger felt by my community who will have to suffer for years from the travesty of this disaster. There is no doubt this salvage has now become the most costly in the history of commercial shipping in the continental United States. Each day the wreck of the Golden Ray lays dead, on its side, in the main channel while dozens of other RoRo’s pass within yards of her, serves the sea’s iron fist of “lessons learned the hard way” for other mariners to observe.
This was excellent, from a retired mechanical engineer. Not a naval architect, but I certainly understand the concepts and wondered how on earth this happened. Thanks.
From a root-cause analysis standpoint, the NTSB was at a disadvantage because they can't quantify greed (nobody can). They can't chart it. But they could certainly measure its effects. They could reverse-engineer the accident, but they couldn't reverse-engineer people's motivations, which is what you did here with sound logic. Great analysis, very insightful.
I wish Government would explain our nations concerns in such a manner. I mean this breakdown really puts things into understanding for people that have no real knowledge. You make it very understandable. Must be one heck of a professor. High graduating class.
I believe the Ch. Mate was carefully adjusting the stability calculations to cover for the operator and maintain his job. Vessel had to discharge 1,500 ton of ballast to make the Arrival Draft Restriction, vessel worked cargo with a net result of 373 tons more cargo onboard sailing thus a greater displacement and draft unless extra cargo was ideally located to decrease the Trim. Unless the Arrival Draft Restriction was tidal and not applicable at sailing, I doubt he could have re-ballasted that 1,500 tons. Tugs can read the actual drafts and relay to the Pilot if out of specs but paperwork only shows the results based on what you input.
I don't know how long you've been doing this kind of work but you certainly seem to have extensive knowledge, I found it relaxing to have you rattling off facts , using this video as a source of background noise. 'liked'
Been watching Capt. Andy for almost a year now. He’s done an awesome job documenting the removal of the ship! Thanks for your analysis of that report. I was wondering why that happened and you described it so a novice could understand.
Glad you enjoy it! I started the channel after the wreck of Ever Given, when I was asked by BBC and a few other media outlets to comment on it. They told me that they liked having me on because I had the shipping experience, I could talk about policy and also the history. Plus, I am comfortable talking on camera. Hence the birth of What's Going on With Shipping.
Hey Sal, thanks for the analysis of the official report and the various articles about the event. You did a great job explaining in layman's terms exactly what caused the vessel to capsize. I think you probably nailed the ultimate cause of the incident (bad data used for ballasting and probably intentional). Who was ultimately responsible? I guess we'll have to wait and see.
Thank you for walking me through this report. Locally we have seen the aftermath of the actions by those trusted to simply so their jobs aboard the Golden Ray. I hope that you will possibly do a segment on large piece removal of ships. This removal has been plagued with problems. MM
So this accident was caused by environmental regulation of ballast treatment plant discharge. Did the drafters of the ballast regulation factor in these economic and environmental costs when they regulated ballast water?
Sal, good job explaining some fairly complicated stability and ship management issues. Perfectly plausible that they had to drop ballast on arrival to meet the port draft restrictions, and then the mate thought he had enough stability to maneuver back to deep clean water to re-ballast to meet the seagoing GM requirement. Agree that NTSB haven't come up with recommendations to address this specific situation. Probably there should be a minimum maneuvering Minimum GM for sheltered waters, as well as the normal Minimum seagoing storm GM.
I think your assessment of the real cause of this mess is 100% on point. The NTSB is used to the aviation industry which has a very different culture than the maritime world, especially foreign flagged vessels. The operation of many of these vessels is subject to little scrutiny other than cost. Crews tend to do the minimum in terms of compliance when the trade off is cost of operations. I agree that in this day, automated monitoring and recording of critical stability data is not only preferable, it should be mandated. The USCG has within its power to require and enforce such a requirement on all vessels entering and leaving US ports. Like you, I think there is a lot that is not brought out in the NTSB’s report on the GOLDEN RAY. With so many of these vessels in US waters, steps need to be taken to ensure this capsize can not happen again.
You will find that Dan Gryder "Probably Cause" (youtube) is equally scathing about the NTSB ability to investigate general aviation accidents and has exposed significant incompetence at the NTSB, you are not alone in your disappointment.
I really can’t blame the NTSB. People think they are given all the formation, I know first hand they are not. They are require to make a report based on what information they are given. I’ve seen them hint to the real reason, but could say it, because all the public information made it look like something else happened. No NTSB report can be relied upon for anything, except pushing the politically correct narrative.
@@ProbableCause-DanGryder hahaha in my neck of the literal woods (Ohio) we say that the way to know if someone is talking about you is if your nose itched. Very clearly, your nose must have itched haha.
Interesting and informative video Sal. Here in the UK we have the Marine Accident Investigation Board (MAIB), they only do maritime related investigations, with the majority of their investigators being ex sea going staff. I think this reports gives us the "How' but not the "Why?" in this incident. I also agree with your opinion regarding the CO not wanting to take on dirty ballast alongside. Hence his winging it till they got to open waters. As they had probably done many times before. Something I'm sure the Master was aware of and probably back in the office they too knew about it. Sadly commercial pressures often cause poeple to take the risk of short cutting statutory regulations. One of the "Whys" that should have been addressed in this report. Anyway keep safe, keep well over your side of the Pond and keep on producing such excellent content.
Really interesting analysis. Had the Golden Ray ever sailed into this port before? What were the conditions then? Same crew? I would think there are multiple vessels in & out of this port with more challenging loads and ballasting requirements. As a non mariner, just the fact where you take on and discharge sea water for ballast is mind boggling. So all these ships are spreading sea water from the opposite side of the globe to another. Hence the ballast tanks treatment plant. There are a lot of moving parts to this accident.
I have been following the Minorcan Mullet for months - this video really explains the background. The theme is the same as so many other mishaps - Look for the simplest explanation and follow the money. I'll be looking for more of your videos.
Sal you review was spot on! I was a summer OD in highschool on the now defunct Suntransport ,Sun Oil tanker system. When loading and unloading product on the Pennsylvania Sun. We we would do Manuel soundings of cargo tanks and report to the bridge . They had an automated system to compare to. Also there were TWO crew mates at each manual soundings station to confirm the readings. Even loading you could see the ship listing . Corrections were done by switching tanks from Port to Starboard and visa versa. Also that old tanker had no ballast treatment system. Brown/Blue water was put in and dumped overboard . Even Butterworthed water when cleaning tanks was 'discarded ' generally out at sea. This was the summer of 1972. I was a painter/deckhand that summer. Pennsy Sun was scraped in the 80ies. Crazy summer job for a teenager. Saw some real Shit holes . Like Lake Maricibo Venezuela.
I'd like to see the report that reviews who's decision it was to cut this ship up as opposed to refloating it like they did in Italy with the Costa Concordia. Cutting it up guaranteed they were going to pollute the Saint Simon's Sound.
Possibly also the inability to unload the cargo (each with a tittle gas bomb included) while the vessel was capsized. That's a lot of randomness to safely rotate.
Captain Andy sent me 🤗 Thank you for a very through explanation…. Now things make sense…. I feel you know exactly why it happened as the saying goes “follow the money “ …. God Bless and Gods Speed 🙏🌹🇺🇸🇺🇸🇺🇸
Thanks for the discussion very informative. My question is where do the lawyers connect in this story. I keep going back to the El Faro story where the lawyers ruined the reputation of some very capable NTSB personnel and Tote skated clean with all the blame placed on the CO and a hand slap to the owners.
We will have to see how the clean up plays out, but the long-term damage to St. Simons will be significant. El Faro is a tough subject. What is amazing is how little was done to improve safety, such as open lifeboats and weather routing. TOTE should have been brought to task.
Great explanation of the report Sal! I appreciate your thoughts on this. Been following Minorcan Mullet channel for some time now. Andy has done a great job documenting the Golden Ray salvage!
I remember the Movie "Away All Boats" with the officer doing stability checks with a wire frame model of the ship adding weights. Simple and relatively accurate. Fudging numbers to avoid work is not safe in aircraft or ships ever.
Having quartermaster do “manual” sounding on a ship that size would taken a lot time. It would have to be done pier side. Recall doing these calculations manually on my destroyer as part of my qualification for DCA. It seems to me that the crew was lucky to have capsized the MV in the channel, once it had reached the open sea it could have capsized and sank as it turned northward toward its next port of call if they were lax in ballasting down. PS1- appreciate your insights on NTSB report. PS 2-compared to the wreck removal of MV Tricolor, this wreck removal deserves its own NTSB or USCG After Action report on failures associated with wreck removal.
Terrific episode and fascinating analysis whose conclusion I agree with heartily. Interesting that two of the commenters mention Dan Gryder and his “PROBABLE CAUSE” TH-cam channel. His aviation analysis and NTSB critiques are well founded and entertaining as well. Thanks Sal.
I thoroughly enjoyed your analysis of this report. It was well thought-out and clearly expressed. The comment about the Ch. Mate not being interviewed caught me off guard, but I saw you clarify that later in the video. I got the sense, however, that you might not have read the Chief Mate's interview on the docket page on the NTSB website. If you haven't, I recommend reading it and the other Incident Docket materials. I think it explains a lot. The C/M's interview was a series of softball questions which the Ch. Mate semi-answered in broken English. By semi-answered I mean he would provide answers to different questions not asked by the interviewer. A rather difficult read. I tend to agree with you that the erroneous entries were likely intentional due to the requirements of the ballast system. I think there was a misconception here that the required GM numbers were necessary in a seaway, not really necessary in flat calm water. Subscribed! - I look forward to more videos!
Enjoyed the details on this accident. Tend to disagree with you about aviation reports. The NTSB typically gets things very wrong for GA accidents. For Air Transport category aircraft they spend the time, money and get good detail of the issues. Most of the time. For GA, they miss the obvious questions (like they did here) more often than not.
wow and more wow i only just this last week became aware of the Golden Ray capsize (now into its second year) i'm in the UK and been binge watching all of the Minorcan Mullet videos (well worth watching), what a crazy mess - it was funny because i had become interested in a similar accident in the UK and the report mentioned similar faults, chiefs mate second guessing ballast loads (with many gauges not working as well and tbh shouldn't have operated AT ALL) he timed the amount of ballast taken on, but i also read this statement that it was common place for water to only be taken on while at sea because of the water treatment predicament you also mentioned - i mean if your going to shoot your feet off why not use both barrels and for good measure do it twice - the mind does really boggle at the mentality of both operators crews and leaving the pilots door open with no in attendance is just too mental - no one seems to learn from previous roro accidents such as the herald of free enterprise at Zeebrugge - i remember that well and will never forget it just maybe the operators and crews should attend a seminar with ships architects to show why ballast tanks are necessary - if numbers don't add up don't take the car out the garage - and stop trying to save money and take short cuts because your just putting lives at risk not to mention the environment and impact on the surrounding area and population - Golden Ray and many other incidents are on the increase PS great video will read the NTSB report as well
Wow! Fascinating analysis as always! All I could think about was the Eastland disaster in Chicago. Same issue with overloading and stability. I agree that the NTSB report seems to be inadequate, but their conclusions are fine. They do not generally discuss in their reports on aviation disasters about why pilots made the errors they did, so it does not surprise me that they do not mention the thinking of the Chief Officer here either. The NTSB is tasked with an enormous amount of work these days, having to cover not only aviation and maritime disasters but also bus, train and even car accidents. I doubt that they have enough staff for more thorough investigations, so that's probably why it takes them so long to complete reports. The questions you raise though are certainly important ones that could have been better addressed in the NTSB report. Thank you for another great video!
One of the really valuable features of your videos is the bits of knowledge I gather about the basic workings of the vessels, in this case the issues surrounding the ballast systems of these ships and how they work. Although I don't quite understand the intricate workings of the way the computer data input is done I can see that when human error enters the picture, which apparently was the case here, things can go sideways (no pun intended) in a hurry. Thanks again for the ongoing education of this 73 year old.
As a "pilot" of the aviation kind, I found the similarities between shipping and flying amazing. We need to be very careful about aircraft loading for the same reason: static and dynamic stability. (But we have Center of Lift, rather than Buoyancy). One thing that differs: NTSB aircraft accident investigations show more scrutiny of organizations and their management. If an individual screws up this big in aviation, there will be a lot more questions like: - who certified this person capable to do the calculates in the first place? - what sort of recurrent exams this person had to endure to ensure his/her knowledge is up to date? - who has supervised and double-checked this person's work that lead to the accident? - who had to ensure that the supervision takes place in reality, and what methods (e.g., audits, post-trip report) were used for that? - what other similar accidents happened before, and why existing prevention/safety recommendation failed during (or succeeded in avoiding) similar accidents? - what legal / certification / permission actions can secure that the U.S. is protected from companies, organizations, individuals that don't adhere to the safety requirements? In short, NTSB aviation branch seems to have a stronger desire to look behind individual actions, and if one person fails to do such an important job, they want to catch everyone that was a willing or unwillling complicit.
There ought to be separate boards, air land and sea, each with it's own experts, maybe under the umbrella of an ntsb, but separate investigating divisions
Here is a theory. Given that this port specialises in car carriers, and that none of them would want to ballast up with dirty water, the pilot would almost certainly have known of the practice of going out unstable, as most of them would do that. To that end, the automatic ballasting system had probably been turned off intentionally and incorrect figures input intentionally. It is likely that all the car carriers do just that, possibly at most ports. Lets face it, they fall over quite regularly. So when the pilot misjudged the turn the first mate takes a bullet to save all the other car carriers, so they can continue this practice. I wouldn't be surprised if the first mate recieved a nice payout in his foreign bank account. Just a thought.
@@easternwoods4378 Nah, sugar is always better than vinegar for sweetening a pot, threats and blackmail are far less effective than a payout. Taking a payout also implicates them as conspirators if they talked, plus you get the "if that person is so incompetent why did they get rehired later?" situations where a person mentioned as a partial cause in an incident but reappear in the same industry later on as its brushed under the carpet.
A couple of points to raise…. 1) None of the diagrams showing the balancing forces etc. mention the significant turning / tipping force that started the whole incident, i.e. the push of the port ship’s side resisting sideways motion and starting the heel. The square side shape of the hull then digs in even further and that force keeps increasing against the righting moment. 2) The report should have recommended increased enforced and possibly punitive oversight by a proper organisation with power and authority such as the Coastguard and Port Authority, until a defective (or otherwise) shipping company proved its competence and integrity. 3) Port Authorities should be motivated and empowered to exclude shipping companies from operating in their ports when they are shown to be unsafe and unethical 4) You don’t question why the ship did not replace the discharged ballast at sea after leaving Jacksonville. Nice video as always…
I'm currently about 17 min. into the video. The phrase that keeps running through my head as the errors and oddities get pointed out is "Checks have been written".
Sounds like the NTSB needs to hire some investigators as well as the engineers who just look at the numbers. The other issue is if the NTSB had some "guidance" about what to investigate. It would seem that they should have let the pilot know the situation so that he could have kept the speed down or just required the pilot to run a slower speed because of some made up story. I"m not a mariner but when you know you are in an iffy situation you tiptoe untill you have it sorted. Or did the captain not know the pilot was going to turn that hard, or being new to the ship he did not know what the mates were doing on the down low. But I suppose the result was a finding that the Mate was "stupid" not criminal worked for most parties while keeping the lawsuits to a minimum.
Awesome video very informative great on pulling apart all the details so us average Joe land lovers could understand it thank you for all your hard work keep it up 🙂🙂🙂🙂
The NTSB has been doing equally shabby work on the aviation side as well. The NTSB has been being run by people that hold their positions due to political favors, not because they are qualified. The whole NTSB is pretty much as big an embarrassment as the rest of our federal government.
With a ship this new one would assume the problem was human error, at least at first. I'm surprised the NTSB didn't come to the same conclusion, but you know what they say about assumptions... A ship I was on left a similar door unsecured, and halfway between Oakland and Long Beach a big mess occurred when a couple thousand gallons of seawater rolled around on an engine deck, knocking stuff around and spilling some solvent. But no real damage done, and the cause was clear: the bosun had a heart attack as we were preparing to depart!
We had a similar incident with the Hoegh Osaka off the south coast of the UK only a few years previously. It was salvaged very quickly by ballasting/pumping water out so that even with a list, it could be re-floated and towed to a nearby port. It should have been possible to do the same with the Golden Ray, if only the correct salvage company had been involved
@@williamlloyd3769 Indeed, Tricolor was different from Hoegh Osaka but was salvaged by a company with relevant experience. As I posted on one of MM's excellent videos a while back, Golden Ray was in too sensitive a location for the salvage operation to be awarded to an organizational with no direct relevant experience of slicing up a large vessel with vehicles as cargo. Sadly the locals and marine life will suffer for years as a consequence
@@williamlloyd3769 Here's a brief summary of what happened with the Hoegh Osaka, Seems that no lessons were learned. Note that this vessel was recovered from a list of about 50 degrees, with no oil spillage or other environmental impact in stark contrast to what's happening with the Golden Ray: th-cam.com/video/b2WJm5w2CVg/w-d-xo.html&ab_channel=MarineAccidentInvestigationBranch
Good report. NTSB well not shining at the moment as per all the comments about Dan Grider. The trick is knowing the questions to ask. For that, you need personal with background knowledge. Same problem as the flying wing of the NTSB in general aviation. Would it have been an idea for the port of Brunswick to offer strained water? Can't be the only ship having that difficulty. Maybe that just to idealistic, Huh?
The fact that there was a comment on its incoming side saying that it had to decrease ballast in order to be shallow enough for the harbor suggests that perhaps the Army corps of engineers should get out their shovel again.
I've seen some of your previous videos, but here today because Capt. Andy mentioned your review of the NTSB report. Thank you so much for taking the time to explain all of this to us amateurs! Two questions: Would it have been a "good idea" and/or common practice for the Golden Ray to have taken on more ballast while they were in cleaner water between Jacksonville and Brunswick? Could they have entered the harbor with a bit deeper draft, then pumped out some ballast to compensate for the 373 MT of added cargo? If the pilot and/or master were aware that they were leaving port with insufficient ballast, couldn't they have taken broader turns at a slower speed to get the ship out into blue water safely so they could take on ballast? Two wrongs don't make a right, but if you know you don't have stability, you could at least take it easy and keep the ship right side up!
David...thanks for subscribing. On your first question, the issue has to do with the coordination between the customer and the ship. If the ship is given the requisite information on number of vehicles, weights (which they say they were not given), and what decks they want to load on, then they can develop a ballast plan. The issue here is the hurried nature of the business and the fact that they basically wait until they are loaded and then determine what ballast they need. On your second question, if the pilot was aware of the tender condition of the ship, he could have not sped up the ship and taken the last turn slower and easier, with less rudder commands and it would not have led to the capsize. But according to his testimony he was not informed about the condition of the ship.
Very interesting video, congratulations for your explanations. Some years ago a similar vessel (Modern Express) experienced a sudden list in the Biscay Bay. She was salvaged hours before grounding and towed in a Spanish port. During the investigation it was found that the bridge computer hard disk hard been removed. Most likely, my guess, by crew before they were airlifted. The only information related to draft and ballast available for the investigation were found in the engine room on a written display ….
Sal, don’t expect the aviation world to have anything but similar opinions of the NTSB as you. Although the NTSB does the aircraft investigations, they have lost all aviation experience at the leadership positions. Two years is much the normal these days. Poor and incompetent reports have become common. Just think of the impact to the port (any port) had the ship blocked the access to and from.
Quite illuminating. Thanks for the clear explanation. What a waste of resources. It's criminal, really. I can also see the point of draft issues in port, and needing to NOT take on 1,500 tons, however it seems that moving the cargo to compensate potentially could have been an adequate means to still maintain stability? Load everything as low as you can get it. Only utilize the center of the upper decks. But of course, that's an extra expense as well, isn't it? What a nightmare. This should never be allowed to happen again.
The computers could connect to satellite internet and make the salt water soaked hard drives way less of a disappointment *when* this happens again. Could even automate the whole draw/ballast leveling/filling process altogether... if it makes a mess of ballast filters, then maybe the companies will join local initiatives to keep the waters clean. Everyone wants it, whether their reasons be different, we all prefer cleaner waters.
I enjoyed this immensely. Riveting. Like a who-done it novel.I gasped at the gravity v buoyancy illustrations at the end. I have good business, maths and science but no maritime application understanding. These are the greatest Ted talks. 😎👍😎
Would the ship have been okay if they made the final turn slowly? Why didn't they realize they were light on ballast, they'd better be extra careful until they added ballast later? Sounds like they got lucky before so didn't realize the risk.
Great analysis, particularly of WHY he didn't re-ballast. I've seen other analyses of this, but had not heard it was a Korean ship. With their disgraceful shipping history, lack of accountability, their appalling apathy toward safety, and their pension to put profit over it, they should be held to account, and I absolutely disagree that there is nothing we can do. It was almost a half-century ago at age 12, when I first saw the also-appalling Japanese Dolphin Slaughter. I asked, "Why don't we tell them we won't buy their cars until they stop that?" So simple, so logical, and so true -- much like the solution to the Brunswick cleanup would and SHOULD be. It would go like this, "Get back here and pay every penny to clean up every drop of every stinking pollutant, compensate the citizens impacted -- and until you do, to OUR satisfaction, you can keep your cars and your reckless ships out of OUR WATERS, and that's FLAT and FINAL." -- It's literally THAT simple. The problem is our Nation's decades and decades of feckless, corrupt leadership that, whether politically or monetarily, absolutely REFUSE to hold ANYONE accountable for ANYTHING. They CAN -- they CHOOSE not to, so, as the saying goes, "Vote the Bums OUT." I won't even begin to address the NTSB and their equally politicized problems-- there's plenty of other people that cover that with well-deserved RANTS -- but... they too deserve ZERO excuses.
You are getting into deep water here, what about reciprocity? What about trade agreements? What about whose side are you on? Communism or Democracy? What about the haves and the have nots? What about the tragedy of the commons?
How about creating a settling pond near muddy ports like gold miners do to clarify water. Then barges could deliver it for ballasting. Yes, Dan Gryders flying channel alleges NTSB has gone rotten from bad appointments at top levels, and they miss the looming root cause in all the technicalities.
The whole operation of the ship screams complacency and normalisation of deviation. Cut corners on ballasting, save time getting underway by closing up the ship as you leave port, lack of proper cross checking of processes. My understanding is that pilot doors are supposed to have a watertight door INSIDE the outer shell, as well as the watertight outer shell door. Why would you have both open, even in calm water? Doesn't the fact there are two doors suggest it would be prudent to keep one closed when the other is open? One has to wonder- if they'd assured integrity of the watertight doors before leaving the berth (and secured the pilot access door), they MAY have been able to recover the ship, or at least have kept her afloat and put her gently on a sand bar or beach somewhere.. Several car carriers have got the leans in the past, but few sink. Car carriers, despite being large, bulky and intrinsically much more top heavy than say a bulk carrier, gain one big advantage with the sheer bulkiness and high freeboard of their hulls- as they list way past normal, as long as the watertight integrity of the immersed hull sides remains intact, the centre of buoyancy rapidly climbs upwards along the side of the ship and ends up balanced again against CG (albiet with a permanent list)
Sal, agree with your assumptions about Ch. Mate inputs to Loadcom. Additionally to the cost element of the ballast water treatment system effluent, is the time element…was there enough time to treat 1500 tons of new ballast water before departure? As for Loadcom inputs from ballast tank sensors, in my experience, those tank sensors are not always reliable or accurate, making manual inputs necessary. In addition, fuel weights matter and if the engineers are not cooperative with which tanks to draw fuel from, stability can be affected. Fuel is ballast too, as you know. NTSB missed the mark on the BWT system.
I thought about the sensors, but they testified that the bosun sounded the tanks and verified the readings. No matter what, the incorrect readings were never addressed in the report. Thanks for watching.
I don't know how much water costs down there but 1500 tons of water is 359,470 gallons. I pay $2.26 per 1,000 gallons, so that would be $760 worth of water. I'm sure the problem would be getting the water to the ship from the water distribution system. But the question is, how much cost does it add to treat the muddy ballast water? It's got to be cheaper than what this is costing them.
25:46, how the hell can the first mate calculate the stability of the ship, if no one knows what the weight distribution of the cargo is. if that was a container ship, that would be criminal to not know the weight of the cargo being loaded.
Container ships have the same problem. They use weights declared by the shipper. It is well known that shippers routinely lie in order to save money. Containers are not weighed as they are loaded.
Enjoying Your Reports Sal👍 Perhaps already stated in comments & or since addressed by You re aviation Reports. I know Channels like Dan Gryders' Probable Cause have more than a few bones to pick re FAA & NTSB Reports > of course the time they always take & often it is that We find the info in these Alphabet Reports are suspect. Seems to me there's very much a systematic problem with both aviation & maritime accident Alphabet Reporting. However thanks to channels such as Yours, We have the option to plug into other, far more astute observations by knowledgeable Industry Professionals like Yourself. Thanks Sal for providing a most invaluable service 🙏
Ships have tow "load :Lines" or Plimsol lines indicating the maximum depth of the submerged hull. If the water is higher than the Plimsol lines the ship wil be unstable.
"center of Gravity never changes" -Well, to nitpick, it shouldn't but it can. Generally means that something is moving inside the ship, probably cargo that is not properly stowed. Or as a secondary effect from another problem (an accident that removes fuel/ballast unevenly, adds flood water, knocks off part of the superstructure etc) that can be a major contributor to further issues. But if you CoG is moving you've got BIG issues.
I'm just glad that the ship did not make it into the Atlantic, and in some bad weather, when it capsized. At least this close to shore, rescue was probably fast and effective. No hands lost.
My take is simple, Pilot is aboard after departing terminal and making a few minor turns in the channel, he should have alarm bells in his head.....tenderness when giving rudder commands, in a nutshell...he should have slow belled the 62° turn knowing the stability issues....all would have ended well, the pilot accsess hatch was open because he would be utilizing it shortly, I put it on the State Pilot for not having the awareness to not tempt fate
My issue with the pilot hatch is leaving it unattended. It is a hard read on the tenderness as she was only doing 2 or 3 turns and his objective is also to get the ship out.
@@wgowshipping those ships are notorious for stability issues, used to see em taking 2-3° lists just steering across Gatun lake in The Panama Canal, i still think a reduction in speed would have averted the whole screwup
@@jamestaylor9603 I entirely agree with you and that should have been communicated by the Chief Mate to the Master. Or the Master should have known if he had the accurate readings on the GM of the ship. There is a lot blame here and not solely the Chief Mate.
I just retired from the M/M's. This happened approx. 40+ mi's north from me. I was curious on what A.B.S. & C.G. had to say about this. It sounds like improper watch standing on the C/M's part. I wonder will he have his Capt.'s license revoked? Thanks for the video Great info.
Get Dan Gryder on for his opinion of the NTSB. Aside from the pollition, I understand why they made the decision to cut the ship up. Trying to refloat it in one piece probably would have been an impossible task.
Seconding the recommendation to check out the "Probable Cause: Dan Gryder" channel. You might want to subscribe and then keep an eye out for upcoming videos related specifically to his opinion of the NTSB. His channel was recently hacked and a number of videos were removed, including those which explore the reasons behind his opinions about the NTSB. He has talked about planning to release more along those lines and I think you will find them interesting when he does.
There were rumours that the ship was not ballasted properly since they wanted to ballast when in open water, to use cleaner ocean water rather than "dirtier" water from the docking area. If so, this is criminal. Also, shouldn't the stability/ballast calculations have been checked by a second person to verify their accuracy before sailing was permitted? Furthermore, didn't a sister ship capsize in similar fashion not that long before the Golden Ray capsized, indicating a fundamental problem with either the design of the ships OR the company operating them?
Looking at just the report, there was no problem with the ships design, just the operating of it. You can see that it is stable just with the eye alone. (If you know what you are looking at).
Saw a report, not able to independently verify however, that this wreck removal is going to wind up being costlier than the COSTA CONCORDIA removal, which is certainly a red flag. My experience is on tankers and containerships, and not recent anymore, but even I know that these ships are a higher risk for this type of incident in both intact and damage stability scenarios - there is a significant history of them doing it. So its definitely doesn't pay to cut corners.
The NTSB was "influenced" by someone, probably a well-connected prominent Washington attorney hired by the company. Thats how things work nowadays, folks. Would explain matters not asked, not explained, witnesses not called, etc.
The NTSB may well have missed some things here, but I think a big part of what you are responding to is the "voice" of a NTSB report. There is a certain scope and attitude. The feeling is perhaps a bit like: "You good sirs are officers and gentlemen, and it goes without saying that you have nothing but the best interests of the public at heart, but... " I believe it is standard that every report begins with a statement that this is *not* about assigning blame, it is about making sure that this does not happen again. When they say that the accident is because the first mate (?) did not properly perform the stability analysis, they leave unsaid "of course nobody would sail if they knew there ship was going to capsize". I do not know what they did and did not know, but in what reports I have seen where perhaps someone was "cutting corners" (where *we* would assume self-interest), the attitude is more like, they ask "why did you do this unsafe thing?" If the person says "I thought it was OK", then that's a "training problem". If it is company policy, then they tell the company they had not done proper safety analysis when the made this policy. I don't know the history of this voice, but I think it is related to the "no fault" attitude toward anonymous reporting of near-accidents. The idea seems to be to focus on the immediate causes of an incident because this is in some sense more actionable. Crew can be pushed to do unsafe things, but if they understand the risks better then they will likely be less unsafe, since they don't want to die. And if it is a company policy, then the company gets publicly told that it is an unsafe policy. At least within aviation, safety authorities around the world seem to pretty closely follow precedents set by the FAA, even though they don't officially have authority outside the country. re. your remark about how the ballast info could be uploaded, and decisions could be monitored in that way. This is precisely what is now done in aviation. If you land too fast, you get a phone call a few days later asking what happened. I don't understand the details of how this information is used, who has access to it for what purposes, but the emphasis seems to be on avoiding the problem. Even if the company wants to cheat, if the regulator forces them to institute this monitoring system, then cheating gets hard, because it is all a matter of record. Nobody has to tell the officers and gentleman that they are liars and cheats. You seemed puzzled about the loading plan not including weight info. I wonder if the real purpose of the loading plan is mainly a matter of "seating", getting the vehicles located where they can be loaded and unloaded at the right port without having to shuffle things around. It would seem from the report that the crews do not worry about this very much. I don't know how that works, but perhaps cars are similar enough in weight, and it all averages out.
Henrik...that is the big question. There is two insurance groups, H&M (Hull & Machinery) and P&I (Protection & Indemnity). This would fall under H&M although P&I would have to pay for some under General Average. It depends on the ultimate cost which is over $800M now.
@@wgowshipping Ok thank you for quick response. What I'm aiming at is that a correctly loaded and barlasted vessel will not turn over! So this is no acident but the result of bad seamanship, incompetent personnel, neglecting rules, taking chances, bad company management, ....... And the insurance companies still pays the bill?
Sir: NTSB investigations, or Casualty Investigations as per IMO MSC Circulars, are based on facts and observations, not fictional assumptions such as the ones you have made. Human factors include errors by the crew -including negligence-. Malice doesn't not need to be involved. PS. Pilots are not caddies. That is an extremely disrespectful analogy.
The fiction here is that the NTSB failed to ascertain why the ship did not load ballast when even with the inaccurate readings inputted by the Chief Mate had a GM below the permitted amount. They failed to ask why the ballast tanks with water in them were only half full and allowed for free surface to add to the issue. Also, I know and work with many pilots. The analogy is meant to convey that pilots assist but do not relieve the master of their ultimate responsibility. My statements are based on the material report and my discussing this issue with two chief mates currently serving on board car carriers but did not want to become public.
Very Interesting real world prospective. If taking on ballast (dirty river water) is issue- why do ports not make clean water ballast available to take on and off as needed?
As a layman I would ask, if the 1st mate has the ability to fudge these calculations for whatever motive, does he then also have the ability to dictate the speed and other factors during the relative maneuvers? seems like a huge gamble if he does not, and the master assumes that all is in order. an so we have this incident.
Golden Ray salvage completed this week. So it took almost 2 years to finish the review, and how long to salvage? Yes, I am coming over from MMs TH-cam.
So to get into the Dunkirk GA port 1500 tons of ballast was pumped out and when leaving the Dunkirk port, at no time was the 1500 tons of ballast pumped back into the Golden Ray. Then exiting that bay turning 68 degrees it rolled over. You note the NTSB report stated the chief mate input the ballast mathematical numbers manually and without anyone else checking his numbers! The ballast numbers manually input were incorrect! You seem to imply this was all done intentionally, obviously not to roll the ship but for saving money by cutting corners reducing the need to overwork the onboard ballast treatment center, treating brown mucky bay water and instead waiting to get into the ocean to ballast with pumped in blue cleaner ocean water . You note there was no need to manually input ballast numbers and instead they could be read electronically automatically by turning on the electronic panel to feed the onboard computer. Why wasn’t this done? because it would kick in automatically that more ballast would be pumped in while in the bay, causing an expense treating this mucky filthy water at a later time. From reading some of the comments by more knowledgeable people on this topic, this seems to be a common practice. As a foreign vessel little can be policed to get to the bottom of what really happened and the whole expensive blunder is swept under the NTSB regulatory carpet. We live in a time of little accountability. Great video and thanks for making these seafaring capsized details so easily understood by anyone not a mariner.
The door tag will not give the weight. It gives the max weight fully loaded. Full fuel passengers and payload. A 1500 truck may have a weight sticker for 7800lbs but weigh around 5600 with a driver and fuel but no real payload.
The door sticker may not, but every manufacturer publishes the empty weigh. In my country empty weight is required on the registration and licence documents.
You are probability right. But if you think that the NTSB isn't doing a good job on the field that you are deeply familiar with, what makes you think they do a better job on everything else you don't feel you already deeply understand?
A while back, Dan did an analysis of the qualifications of the NTSB board, and found a total lack of any member with a pilot's license. Hence the continual moped jokes.
@@SteamCrane The NTSB board isn't supposed to be experts on navigating ships around hurricanes or ballasting vessels or design of flight control software, or bridge design methodologies, or why planes might not rotate after V1. They are there to ensure that they have experts, the experts do their job and that they keep the big picture in mind.
My guess was that they had a uncomfortable rolling than they preferred on the way in, and tried to correct it by increasing the period by making her more tender - thus did a manual calculation to get the metacentric height 'close enough' to a go condition to pass a sniff test, and entered those faked numbers to the computer. It may also have been compromised by taking on cargo - and leaving a previously filled ballast tank now with a free surface. It sounds like an approved, but inappropriate action to suit some or all of the crew's comfort to me... at the expense of safety.
Great stuff Sal. - coming from a risk manager and how the NTSB reports are edited - you have stated clearly a possible issue with human causality - sadly the NTSB editorial process does not get peer reviewed for this and often the logic and accident determination is lost in the engineering ossification . As soon as the vessel left JVF the ballast issue should have been red flagged to the risk company with the LoadCom screaming an issue and never allowed into Brunswick . Your work helps us in a big way and we appreciate everything you do
As you were talking about the report I was screaming to myself…. “The Mate entered the values manually so they could sail and was going to add ballast once at sea”…. You then said the exact same thing. Great job, I do enjoy your videos.
I screamed when I was reading that report.
Also aviation background here, but rubbed soldiers with a number of naval architects and understand that righting arm (G. M.) is a function of listing angle, which is directly impacted by rudder input and forward/tangential velocities.
When you said "...but went to Jacksonville first because of the hurricane...", I got the same feeling down the back of my neck that I did when talking heads on TV, a former professor of mine included, were speculating what significance a foam strike from the Space Shuttle ullage arm could have had on the shuttle tiles, just as the first images of Columbia debris from news footage in Texas began to air.
That is a chilling feeling, and I've only experienced it twice. Today was the third when you mentioned Jacksonville, then Brunswick. I've sailed Jacksonville, I've seen the bridge span there, everybody knows it's a shallow port.
But when the likely cause shifted from suspected incompetence to cost savings (i.e., treatment plant maintenance and dumping fees), I didn't scream, but the back of my neck got hot.
Falsification of ballast inputs, followed by a lack of controlling speed in the maneuvering lanes with oncoming traffic plus a failure to notify the captain or pilot of the compromised condition of the ship's stability did all this to the people of Brunswick, but most importantly, the inhabitants of St. Simon's Island, and it turns out it was all for cost reductions and potential time savings in light of the added delay the out of order port calls caused.
Such a good clarification. Outstanding.
My recollection is that the pilot asked for a speed increase in the final turn when the list began, unwittingly thinking the helm was not responding sufficiently. Had he only known, he would have called for less speed and a wider turn to take the Emerald Ace on her starboard side out of alignment with the channel so as to keep the list to a minimum, but of course, it was too late by then--these aren't sports cars. Most likely they were aware of Emerald Ace's proximity and laid on speed to maintain rudder authority and spacing, assuming ship stability and draft were under control.
You may not be able to say it outright, but I can--this was criminal neglect, not only on the part of the First Mate, but on the operational procedures of the operating company. With zero checks and balances, no oversight, no reviewing of how the data were entered, this was an accident waiting to happen.
Crew Management Resource (CRM) principles, where everyone can note and identify a mistake, would improve the shipping industry. Korean crew with a long cultural history of deferring to--or possibly hiding things from--those in authority is directly responsible for this ecological destruction that did not end with the removal of the last section of ship yesterday.
Thank you for your detailed and animated explanation. This truly is the Warren Commission Report of NTSB reports.
@@macblastoff7700 Thank you for all your comments and nice words. It was a hard video to make but it really bothered me how the NTSB dealt with this.
@@macblastoff7700 That's the most comprehensive review I've read and I think your analysis is exactly on-point. This was a tragedy that I heard quite a bit about here in BC.
Thank you both for your emotional investment into these sorts of things. Like rules in the aviation industry that they say 'are written in blood'; this is a very similar tragedy that I too agree should be bringing criminal charges.
@@wgowshippingTalk to Dan Gryder Probable Cause… aviation safety channel, a bit (no a lot… ) more confrontational and controversial than you but good fun and well intentioned, he’s in Georgia and famously critical of the slow, ineffective and self-satisfied with the NTSB, now led by “Moped Jenny”…
I said this on day one.. They didn't want to pump in Brunswick's brown water.. (Brunswick is a big estuary and is fed by many silted rivers.) and were not In Ballast... I live here... Great report...
you dont consider the that :-
- they had to off load ballast to reduce draft (maintain sufficient bottom clearance) for this port when entering
- they put more wieght on ( more draft)
- they could not put more (the appropiate ammount of) ballast on because they would not have had enough bottom clearance for the port
= ie the possibilty that the ship as loaded was not suitable ( too deep draft) for the port
I would appriciate your thoughts / comments on this
13:00 This sounds exactly like a Dan Gryder report! Historically, the NTSB has consistently asked the wrong questions, not interviewed relevant people, and ignored eyewitnesses.
Great report, subscribed!
Ditto. Also subbed. Great work. Always appreciate someone's evaluation when it is their field of study and life's work.
People with money like to keep the NTSB from costing them money.
Again, sir, your knowledge and experience at sea as a professional deck officer has clearly stated the issues and questions of why this vessel died in the St Simons Sound. There are no clear explanations available from forensic evidence of the vessel’s load and stability computer that was destroyed, why the vessel did not link its realtime engineering status to a remote database for review prior to sailing and why the deck officers were not thoroughly interrogated by USCG before fleeing back to S Korea. Many unanswered questions like these just add to the frustration and anger felt by my community who will have to suffer for years from the travesty of this disaster.
There is no doubt this salvage has now become the most costly in the history of commercial shipping in the continental United States.
Each day the wreck of the Golden Ray lays dead, on its side, in the main channel while dozens of other RoRo’s pass within yards of her, serves the sea’s iron fist of “lessons learned the hard way” for other mariners to observe.
This was excellent, from a retired mechanical engineer. Not a naval architect, but I certainly understand the concepts and wondered how on earth this happened. Thanks.
From a root-cause analysis standpoint, the NTSB was at a disadvantage because they can't quantify greed (nobody can). They can't chart it. But they could certainly measure its effects. They could reverse-engineer the accident, but they couldn't reverse-engineer people's motivations, which is what you did here with sound logic. Great analysis, very insightful.
Ah, but they could, just like Sal.
I wish Government would explain our nations concerns in such a manner. I mean this breakdown really puts things into understanding for people that have no real knowledge. You make it very understandable. Must be one heck of a professor. High graduating class.
Educational, incredible analysis, and should be an award-winning TH-cam video of the most expensive unexpected wrongdoing in shipping.
I believe the Ch. Mate was carefully adjusting the stability calculations to cover for the operator and maintain his job.
Vessel had to discharge 1,500 ton of ballast to make the Arrival Draft Restriction, vessel worked cargo with a net result of 373 tons more cargo onboard sailing thus a greater displacement and draft unless extra cargo was ideally located to decrease the Trim. Unless the Arrival Draft Restriction was tidal and not applicable at sailing, I doubt he could have re-ballasted that 1,500 tons.
Tugs can read the actual drafts and relay to the Pilot if out of specs but paperwork only shows the results based on what you input.
I don't know how long you've been doing this kind of work but you certainly seem to have extensive knowledge, I found it relaxing to have you rattling off facts , using this video as a source of background noise. 'liked'
Been watching Capt. Andy for almost a year now. He’s done an awesome job documenting the removal of the ship! Thanks for your analysis of that report. I was wondering why that happened and you described it so a novice could understand.
Glad you enjoy it! I started the channel after the wreck of Ever Given, when I was asked by BBC and a few other media outlets to comment on it. They told me that they liked having me on because I had the shipping experience, I could talk about policy and also the history. Plus, I am comfortable talking on camera. Hence the birth of What's Going on With Shipping.
Very well done. While on vacation, I actually took pictures of that vessel while it was staging in the river. Unbelievable.
Hey Sal, thanks for the analysis of the official report and the various articles about the event. You did a great job explaining in layman's terms exactly what caused the vessel to capsize. I think you probably nailed the ultimate cause of the incident (bad data used for ballasting and probably intentional). Who was ultimately responsible? I guess we'll have to wait and see.
Ultimately, YOU pay, regardless of responsibility.
To me, inputting data manually that could be input automatically absolutely screams that the chief mate was intentionally fudging the numbers.
Thank you for walking me through this report. Locally we have seen the aftermath of the actions by those trusted to simply so their jobs aboard the Golden Ray. I hope that you will possibly do a segment on large piece removal of ships. This removal has been plagued with problems. MM
I hope he does too Captain Andy.
Wow. I hope Ryfun gets to see this.
So this accident was caused by environmental regulation of ballast treatment plant discharge. Did the drafters of the ballast regulation factor in these economic and environmental costs when they regulated ballast water?
Sal, good job explaining some fairly complicated stability and ship management issues. Perfectly plausible that they had to drop ballast on arrival to meet the port draft restrictions, and then the mate thought he had enough stability to maneuver back to deep clean water to re-ballast to meet the seagoing GM requirement. Agree that NTSB haven't come up with recommendations to address this specific situation. Probably there should be a minimum maneuvering Minimum GM for sheltered waters, as well as the normal Minimum seagoing storm GM.
Excellent point. Consider the unsecured loads thru-out. Foreign or American flag, the load has to be secured.
The video doesn’t explain or question why the ballast wasn’t refilled 1500T at sea AFTER leaving Jacksonville.
@@johnmoruzzi7236 Neither does the NTSB report.
I think your assessment of the real cause of this mess is 100% on point. The NTSB is used to the aviation industry which has a very different culture than the maritime world, especially foreign flagged vessels. The operation of many of these vessels is subject to little scrutiny other than cost. Crews tend to do the minimum in terms of compliance when the trade off is cost of operations.
I agree that in this day, automated monitoring and recording of critical stability data is not only preferable, it should be mandated. The USCG has within its power to require and enforce such a requirement on all vessels entering and leaving US ports. Like you, I think there is a lot that is not brought out in the NTSB’s report on the GOLDEN RAY. With so many of these vessels in US waters, steps need to be taken to ensure this capsize can not happen again.
It will, it is just a matter of time. We have bigger fish to fry.
You will find that Dan Gryder "Probably Cause" (youtube) is equally scathing about the NTSB ability to investigate general aviation accidents and has exposed significant incompetence at the NTSB, you are not alone in your disappointment.
I was looking for this comment, or going to say the same thing. Good ole NTSB!
I really can’t blame the NTSB. People think they are given all the formation, I know first hand they are not.
They are require to make a report based on what information they are given. I’ve seen them hint to the real reason, but could say it, because all the public information made it look like something else happened.
No NTSB report can be relied upon for anything, except pushing the politically correct narrative.
I love to hate Dan Gryder lol. And I hate how right he is all the time. (Joking. Kind of.)
I also agree with Dan Gryder.
@@ProbableCause-DanGryder hahaha in my neck of the literal woods (Ohio) we say that the way to know if someone is talking about you is if your nose itched.
Very clearly, your nose must have itched haha.
Interesting and informative video Sal.
Here in the UK we have the Marine Accident Investigation Board (MAIB), they only do maritime related investigations, with the majority of their investigators being ex sea going staff.
I think this reports gives us the "How' but not the "Why?" in this incident. I also agree with your opinion regarding the CO not wanting to take on dirty ballast alongside. Hence his winging it till they got to open waters. As they had probably done many times before. Something I'm sure the Master was aware of and probably back in the office they too knew about it.
Sadly commercial pressures often cause poeple to take the risk of short cutting statutory regulations. One of the "Whys" that should have been addressed in this report.
Anyway keep safe, keep well over your side of the Pond and keep on producing such excellent content.
Really interesting analysis. Had the Golden Ray ever sailed into this port before? What were the conditions then? Same crew? I would think there are multiple vessels in & out of this port with more challenging loads and ballasting requirements. As a non mariner, just the fact where you take on and discharge sea water for ballast is mind boggling. So all these ships are spreading sea water from the opposite side of the globe to another. Hence the ballast tanks treatment plant. There are a lot of moving parts to this accident.
Captain Andy sent me to this page. Awesome Job explaining this report, thank you.
I have been following the Minorcan Mullet for months - this video really explains the background. The theme is the same as so many other mishaps - Look for the simplest explanation and follow the money. I'll be looking for more of your videos.
Sal you review was spot on! I was a summer OD in highschool on the now defunct Suntransport ,Sun Oil tanker system. When loading and unloading product on the Pennsylvania Sun. We we would do Manuel soundings of cargo tanks and report to the bridge . They had an automated system to compare to.
Also there were TWO crew mates at each manual soundings station to confirm the readings. Even loading you could see the ship listing . Corrections were done by switching tanks from Port to Starboard and visa versa. Also that old tanker had no ballast treatment system. Brown/Blue water was put in and dumped overboard . Even Butterworthed water when cleaning tanks was 'discarded ' generally out at sea.
This was the summer of 1972. I was a painter/deckhand that summer. Pennsy Sun was scraped in the 80ies. Crazy summer job for a teenager. Saw some real Shit holes . Like Lake Maricibo Venezuela.
Great explanation of a very complicated issue. Also, your theory makes as the real reason the ship capsized is brilliant.
I'd like to see the report that reviews who's decision it was to cut this ship up as opposed to refloating it like they did in Italy with the Costa Concordia. Cutting it up guaranteed they were going to pollute the Saint Simon's Sound.
Depends on the room available, the time available, the equipment available, the costs.
Possibly also the inability to unload the cargo (each with a tittle gas bomb included) while the vessel was capsized. That's a lot of randomness to safely rotate.
Captain Andy sent me 🤗 Thank you for a very through explanation…. Now things make sense…. I feel you know exactly why it happened as the saying goes “follow the money “ …. God Bless and Gods Speed 🙏🌹🇺🇸🇺🇸🇺🇸
Thanks for the discussion very informative. My question is where do the lawyers connect in this story. I keep going back to the El Faro story where the lawyers ruined the reputation of some very capable NTSB personnel and Tote skated clean with all the blame placed on the CO and a hand slap to the owners.
We will have to see how the clean up plays out, but the long-term damage to St. Simons will be significant. El Faro is a tough subject. What is amazing is how little was done to improve safety, such as open lifeboats and weather routing. TOTE should have been brought to task.
I was also struck (as Sal mentioned) by the total lack of "real" fixes, which would mitigate future similar errors.
Great explanation of the report Sal! I appreciate your thoughts on this. Been following Minorcan Mullet channel for some time now. Andy has done a great job documenting the Golden Ray salvage!
I remember the Movie "Away All Boats" with the officer doing stability checks with a wire frame model of the ship adding weights. Simple and relatively accurate. Fudging numbers to avoid work is not safe in aircraft or ships ever.
Having quartermaster do “manual” sounding on a ship that size would taken a lot time. It would have to be done pier side. Recall doing these calculations manually on my destroyer as part of my qualification for DCA. It seems to me that the crew was lucky to have capsized the MV in the channel, once it had reached the open sea it could have capsized and sank as it turned northward toward its next port of call if they were lax in ballasting down.
PS1- appreciate your insights on NTSB report.
PS 2-compared to the wreck removal of MV Tricolor, this wreck removal deserves its own NTSB or USCG After Action report on failures associated with wreck removal.
Agree on all points.
you have been in the Navy too long, there are no quartermasters on commercial ships.
They would have ballasted before making any distance, knowing it was wrong.
Terrific episode and fascinating analysis whose conclusion I agree with heartily. Interesting that two of the commenters mention Dan Gryder and his “PROBABLE CAUSE” TH-cam channel. His aviation analysis and NTSB critiques are well founded and entertaining as well. Thanks Sal.
I thoroughly enjoyed your analysis of this report. It was well thought-out and clearly expressed. The comment about the Ch. Mate not being interviewed caught me off guard, but I saw you clarify that later in the video. I got the sense, however, that you might not have read the Chief Mate's interview on the docket page on the NTSB website. If you haven't, I recommend reading it and the other Incident Docket materials. I think it explains a lot. The C/M's interview was a series of softball questions which the Ch. Mate semi-answered in broken English. By semi-answered I mean he would provide answers to different questions not asked by the interviewer. A rather difficult read. I tend to agree with you that the erroneous entries were likely intentional due to the requirements of the ballast system. I think there was a misconception here that the required GM numbers were necessary in a seaway, not really necessary in flat calm water.
Subscribed! - I look forward to more videos!
The questions asked to the CM was ridiculous. I could not believe the level of questioning.
The fact that she sunk shows that it was necessary in calm waters as well.
You present a very good and reasonable point here. Too often safety takes second position to saving money.
Thanks Sal for this great explanation of why this event occurred.
Enjoyed the details on this accident. Tend to disagree with you about aviation reports. The NTSB typically gets things very wrong for GA accidents. For Air Transport category aircraft they spend the time, money and get good detail of the issues. Most of the time. For GA, they miss the obvious questions (like they did here) more often than not.
wow and more wow
i only just this last week became aware of the Golden Ray capsize (now into its second year) i'm in the UK and been binge watching all of the Minorcan Mullet videos (well worth watching), what a crazy mess - it was funny because i had become interested in a similar accident in the UK and the report mentioned similar faults, chiefs mate second guessing ballast loads (with many gauges not working as well and tbh shouldn't have operated AT ALL) he timed the amount of ballast taken on, but i also read this statement that it was common place for water to only be taken on while at sea because of the water treatment predicament you also mentioned - i mean if your going to shoot your feet off why not use both barrels and for good measure do it twice - the mind does really boggle at the mentality of both operators crews
and leaving the pilots door open with no in attendance is just too mental - no one seems to learn from previous roro accidents such as the herald of free enterprise at Zeebrugge - i remember that well and will never forget it
just maybe the operators and crews should attend a seminar with ships architects to show why ballast tanks are necessary - if numbers don't add up don't take the car out the garage - and stop trying to save money and take short cuts because your just putting lives at risk not to mention the environment and impact on the surrounding area and population - Golden Ray and many other incidents are on the increase
PS great video will read the NTSB report as well
Wow! Fascinating analysis as always! All I could think about was the Eastland disaster in Chicago. Same issue with overloading and stability. I agree that the NTSB report seems to be inadequate, but their conclusions are fine. They do not generally discuss in their reports on aviation disasters about why pilots made the errors they did, so it does not surprise me that they do not mention the thinking of the Chief Officer here either. The NTSB is tasked with an enormous amount of work these days, having to cover not only aviation and maritime disasters but also bus, train and even car accidents. I doubt that they have enough staff for more thorough investigations, so that's probably why it takes them so long to complete reports. The questions you raise though are certainly important ones that could have been better addressed in the NTSB report. Thank you for another great video!
One of the really valuable features of your videos is the bits of knowledge I gather about the basic workings of the vessels, in this case the issues surrounding the ballast systems of these ships and how they work. Although I don't quite understand the intricate workings of the way the computer data input is done I can see that when human error enters the picture, which apparently was the case here, things can go sideways (no pun intended) in a hurry. Thanks again for the ongoing education of this 73 year old.
Outstanding explanation, enough technical information to support the analysis without getting too deep into the engineering weeds. Well done.
As a "pilot" of the aviation kind, I found the similarities between shipping and flying amazing. We need to be very careful about aircraft loading for the same reason: static and dynamic stability. (But we have Center of Lift, rather than Buoyancy). One thing that differs: NTSB aircraft accident investigations show more scrutiny of organizations and their management. If an individual screws up this big in aviation, there will be a lot more questions like:
- who certified this person capable to do the calculates in the first place?
- what sort of recurrent exams this person had to endure to ensure his/her knowledge is up to date?
- who has supervised and double-checked this person's work that lead to the accident?
- who had to ensure that the supervision takes place in reality, and what methods (e.g., audits, post-trip report) were used for that?
- what other similar accidents happened before, and why existing prevention/safety recommendation failed during (or succeeded in avoiding) similar accidents?
- what legal / certification / permission actions can secure that the U.S. is protected from companies, organizations, individuals that don't adhere to the safety requirements?
In short, NTSB aviation branch seems to have a stronger desire to look behind individual actions, and if one person fails to do such an important job, they want to catch everyone that was a willing or unwillling complicit.
And yet all this paper work does not stop many people from being killed.
There ought to be separate boards, air land and sea, each with it's own experts, maybe under the umbrella of an ntsb, but separate investigating divisions
I have been in aviation my entire life (I’m 78). Over the last ten years or so the NTSB is doing a LOUSY job of investigating aircraft accidents.
Dots, go check out Dan gryder if you don't know of him.
I wonder if they're hiring based on appearance more than qualifications the past several years.
Yep.
I am looking at the exact spot of the capsized ship here in St. Simons. Now I understand what happened. Great video!
Here is a theory.
Given that this port specialises in car carriers, and that none of them would want to ballast up with dirty water, the pilot would almost certainly have known of the practice of going out unstable, as most of them would do that.
To that end, the automatic ballasting system had probably been turned off intentionally and incorrect figures input intentionally. It is likely that all the car carriers do just that, possibly at most ports. Lets face it, they fall over quite regularly.
So when the pilot misjudged the turn the first mate takes a bullet to save all the other car carriers, so they can continue this practice.
I wouldn't be surprised if the first mate recieved a nice payout in his foreign bank account.
Just a thought.
A few too many assumptions
He's more afraid of taking a real bullet. There's no secret payoff. He's expendable
It's a thought and will stay that way.
Well that sure makes sense. This is a nugget for some investigative reporter out there.
@@easternwoods4378 Nah, sugar is always better than vinegar for sweetening a pot, threats and blackmail are far less effective than a payout. Taking a payout also implicates them as conspirators if they talked, plus you get the "if that person is so incompetent why did they get rehired later?" situations where a person mentioned as a partial cause in an incident but reappear in the same industry later on as its brushed under the carpet.
A couple of points to raise….
1) None of the diagrams showing the balancing forces etc. mention the significant turning / tipping force that started the whole incident, i.e. the push of the port ship’s side resisting sideways motion and starting the heel. The square side shape of the hull then digs in even further and that force keeps increasing against the righting moment.
2) The report should have recommended increased enforced and possibly punitive oversight by a proper organisation with power and authority such as the Coastguard and Port Authority, until a defective (or otherwise) shipping company proved its competence and integrity.
3) Port Authorities should be motivated and empowered to exclude shipping companies from operating in their ports when they are shown to be unsafe and unethical
4) You don’t question why the ship did not replace the discharged ballast at sea after leaving Jacksonville.
Nice video as always…
I'm currently about 17 min. into the video. The phrase that keeps running through my head as the errors and oddities get pointed out is "Checks have been written".
Sounds like the NTSB needs to hire some investigators as well as the engineers who just look at the numbers. The other issue is if the NTSB had some "guidance" about what to investigate. It would seem that they should have let the pilot know the situation so that he could have kept the speed down or just required the pilot to run a slower speed because of some made up story. I"m not a mariner but when you know you are in an iffy situation you tiptoe untill you have it sorted. Or did the captain not know the pilot was going to turn that hard, or being new to the ship he did not know what the mates were doing on the down low.
But I suppose the result was a finding that the Mate was "stupid" not criminal worked for most parties while keeping the lawsuits to a minimum.
Awesome video very informative great on pulling apart all the details so us average Joe land lovers could understand it thank you for all your hard work keep it up 🙂🙂🙂🙂
Glad you enjoyed it
The NTSB has been doing equally shabby work on the aviation side as well.
The NTSB has been being run by people that hold their positions due to political favors, not because they are qualified. The whole NTSB is pretty much as big an embarrassment as the rest of our federal government.
With a ship this new one would assume the problem was human error, at least at first. I'm surprised the NTSB didn't come to the same conclusion, but you know what they say about assumptions...
A ship I was on left a similar door unsecured, and halfway between Oakland and Long Beach a big mess occurred when a couple thousand gallons of seawater rolled around on an engine deck, knocking stuff around and spilling some solvent. But no real damage done, and the cause was clear: the bosun had a heart attack as we were preparing to depart!
I think you hit the nail on the head - cost cutting - as to the salvage procedure - what were they thinking?
We had a similar incident with the Hoegh Osaka off the south coast of the UK only a few years previously. It was salvaged very quickly by ballasting/pumping water out so that even with a list, it could be re-floated and towed to a nearby port. It should have been possible to do the same with the Golden Ray, if only the correct salvage company had been involved
Salvage was a cluster compared to the similar wreck removal of the MV Tricolor.
@@williamlloyd3769 Indeed, Tricolor was different from Hoegh Osaka but was salvaged by a company with relevant experience. As I posted on one of MM's excellent videos a while back, Golden Ray was in too sensitive a location for the salvage operation to be awarded to an organizational with no direct relevant experience of slicing up a large vessel with vehicles as cargo. Sadly the locals and marine life will suffer for years as a consequence
@@williamlloyd3769 Here's a brief summary of what happened with the Hoegh Osaka, Seems that no lessons were learned. Note that this vessel was recovered from a list of about 50 degrees, with no oil spillage or other environmental impact in stark contrast to what's happening with the Golden Ray: th-cam.com/video/b2WJm5w2CVg/w-d-xo.html&ab_channel=MarineAccidentInvestigationBranch
Good report. NTSB well not shining at the moment as per all the comments about Dan Grider. The trick is knowing the questions to ask. For that, you need personal with background knowledge. Same problem as the flying wing of the NTSB in general aviation. Would it have been an idea for the port of Brunswick to offer strained water? Can't be the only ship having that difficulty. Maybe that just to idealistic, Huh?
The requirement would be for tons of water. This is still an issue and that is one of the reasons I called out the NTSB.
The fact that there was a comment on its incoming side saying that it had to decrease ballast in order to be shallow enough for the harbor suggests that perhaps the Army corps of engineers should get out their shovel again.
I've seen some of your previous videos, but here today because Capt. Andy mentioned your review of the NTSB report. Thank you so much for taking the time to explain all of this to us amateurs! Two questions:
Would it have been a "good idea" and/or common practice for the Golden Ray to have taken on more ballast while they were in cleaner water between Jacksonville and Brunswick? Could they have entered the harbor with a bit deeper draft, then pumped out some ballast to compensate for the 373 MT of added cargo?
If the pilot and/or master were aware that they were leaving port with insufficient ballast, couldn't they have taken broader turns at a slower speed to get the ship out into blue water safely so they could take on ballast? Two wrongs don't make a right, but if you know you don't have stability, you could at least take it easy and keep the ship right side up!
David...thanks for subscribing.
On your first question, the issue has to do with the coordination between the customer and the ship. If the ship is given the requisite information on number of vehicles, weights (which they say they were not given), and what decks they want to load on, then they can develop a ballast plan. The issue here is the hurried nature of the business and the fact that they basically wait until they are loaded and then determine what ballast they need.
On your second question, if the pilot was aware of the tender condition of the ship, he could have not sped up the ship and taken the last turn slower and easier, with less rudder commands and it would not have led to the capsize. But according to his testimony he was not informed about the condition of the ship.
Very interesting video, congratulations for your explanations. Some years ago a similar vessel (Modern Express) experienced a sudden list in the Biscay Bay. She was salvaged hours before grounding and towed in a Spanish port. During the investigation it was found that the bridge computer hard disk hard been removed. Most likely, my guess, by crew before they were airlifted. The only information related to draft and ballast available for the investigation were found in the engine room on a written display ….
Sal, don’t expect the aviation world to have anything but similar opinions of the NTSB as you. Although the NTSB does the aircraft investigations, they have lost all aviation experience at the leadership positions. Two years is much the normal these days. Poor and incompetent reports have become common.
Just think of the impact to the port (any port) had the ship blocked the access to and from.
Quite illuminating. Thanks for the clear explanation. What a waste of resources. It's criminal, really. I can also see the point of draft issues in port, and needing to NOT take on 1,500 tons, however it seems that moving the cargo to compensate potentially could have been an adequate means to still maintain stability? Load everything as low as you can get it. Only utilize the center of the upper decks. But of course, that's an extra expense as well, isn't it? What a nightmare. This should never be allowed to happen again.
The computers could connect to satellite internet and make the salt water soaked hard drives way less of a disappointment *when* this happens again. Could even automate the whole draw/ballast leveling/filling process altogether... if it makes a mess of ballast filters, then maybe the companies will join local initiatives to keep the waters clean. Everyone wants it, whether their reasons be different, we all prefer cleaner waters.
I enjoyed this immensely. Riveting. Like a who-done it novel.I gasped at the gravity v buoyancy illustrations at the end. I have good business, maths and science but no maritime application understanding. These are the greatest Ted talks. 😎👍😎
Would the ship have been okay if they made the final turn slowly? Why didn't they realize they were light on ballast, they'd better be extra careful until they added ballast later? Sounds like they got lucky before so didn't realize the risk.
Great analysis, particularly of WHY he didn't re-ballast. I've seen other analyses of this, but had not heard it was a Korean ship. With their disgraceful shipping history, lack of accountability, their appalling apathy toward safety, and their pension to put profit over it, they should be held to account, and I absolutely disagree that there is nothing we can do.
It was almost a half-century ago at age 12, when I first saw the also-appalling Japanese Dolphin Slaughter. I asked, "Why don't we tell them we won't buy their cars until they stop that?" So simple, so logical, and so true -- much like the solution to the Brunswick cleanup would and SHOULD be. It would go like this,
"Get back here and pay every penny to clean up every drop of every stinking pollutant, compensate the citizens impacted -- and until you do, to OUR satisfaction, you can keep your cars and your reckless ships out of OUR WATERS, and that's FLAT and FINAL." -- It's literally THAT simple.
The problem is our Nation's decades and decades of feckless, corrupt leadership that, whether politically or monetarily, absolutely REFUSE to hold ANYONE accountable for ANYTHING. They CAN -- they CHOOSE not to, so, as the saying goes, "Vote the Bums OUT."
I won't even begin to address the NTSB and their equally politicized problems-- there's plenty of other people that cover that with well-deserved RANTS -- but... they too deserve ZERO excuses.
You are getting into deep water here, what about reciprocity? What about trade agreements? What about whose side are you on? Communism or Democracy? What about the haves and the have nots? What about the tragedy of the commons?
How about creating a settling pond near muddy ports like gold miners do to clarify water. Then barges could deliver it for ballasting. Yes, Dan Gryders flying channel alleges NTSB has gone rotten from bad appointments at top levels, and they miss the looming root cause in all the technicalities.
Excellent video Sal , keep up the great work.
The whole operation of the ship screams complacency and normalisation of deviation. Cut corners on ballasting, save time getting underway by closing up the ship as you leave port, lack of proper cross checking of processes. My understanding is that pilot doors are supposed to have a watertight door INSIDE the outer shell, as well as the watertight outer shell door. Why would you have both open, even in calm water? Doesn't the fact there are two doors suggest it would be prudent to keep one closed when the other is open?
One has to wonder- if they'd assured integrity of the watertight doors before leaving the berth (and secured the pilot access door), they MAY have been able to recover the ship, or at least have kept her afloat and put her gently on a sand bar or beach somewhere.. Several car carriers have got the leans in the past, but few sink.
Car carriers, despite being large, bulky and intrinsically much more top heavy than say a bulk carrier, gain one big advantage with the sheer bulkiness and high freeboard of their hulls- as they list way past normal, as long as the watertight integrity of the immersed hull sides remains intact, the centre of buoyancy rapidly climbs upwards along the side of the ship and ends up balanced again against CG (albiet with a permanent list)
Sal, agree with your assumptions about Ch. Mate inputs to Loadcom. Additionally to the cost element of the ballast water treatment system effluent, is the time element…was there enough time to treat 1500 tons of new ballast water before departure? As for Loadcom inputs from ballast tank sensors, in my experience, those tank sensors are not always reliable or accurate, making manual inputs necessary. In addition, fuel weights matter and if the engineers are not cooperative with which tanks to draw fuel from, stability can be affected. Fuel is ballast too, as you know. NTSB missed the mark on the BWT system.
I thought about the sensors, but they testified that the bosun sounded the tanks and verified the readings. No matter what, the incorrect readings were never addressed in the report.
Thanks for watching.
I don't know how much water costs down there but 1500 tons of water is 359,470 gallons. I pay $2.26 per 1,000 gallons, so that would be $760 worth of water. I'm sure the problem would be getting the water to the ship from the water distribution system. But the question is, how much cost does it add to treat the muddy ballast water? It's got to be cheaper than what this is costing them.
@@robertjune1221 Thanks for those numbers! Getting dizzy from shaking my head (SMH)!
25:46, how the hell can the first mate calculate the stability of the ship, if no one knows what the weight distribution of the cargo is. if that was a container ship, that would be criminal to not know the weight of the cargo being loaded.
Container ships have the same problem. They use weights declared by the shipper. It is well known that shippers routinely lie in order to save money.
Containers are not weighed as they are loaded.
Enjoying Your Reports Sal👍
Perhaps already stated in comments & or since addressed by You re aviation Reports.
I know Channels like Dan Gryders' Probable Cause have more than a few bones to pick re FAA & NTSB Reports > of course the time they always take & often it is that We find the info in these Alphabet Reports are suspect.
Seems to me there's very much a systematic problem with both aviation & maritime accident Alphabet Reporting.
However thanks to channels such as Yours, We have the option to plug into other, far more astute observations by knowledgeable Industry Professionals like Yourself.
Thanks Sal for providing a most invaluable service 🙏
Ships have tow "load :Lines" or Plimsol lines indicating the maximum depth of the submerged hull. If the water is higher than the Plimsol lines the ship wil be unstable.
"center of Gravity never changes" -Well, to nitpick, it shouldn't but it can.
Generally means that something is moving inside the ship, probably cargo that is not properly stowed. Or as a secondary effect from another problem (an accident that removes fuel/ballast unevenly, adds flood water, knocks off part of the superstructure etc) that can be a major contributor to further issues. But if you CoG is moving you've got BIG issues.
I'm just glad that the ship did not make it into the Atlantic, and in some bad weather, when it capsized. At least this close to shore, rescue was probably fast and effective. No hands lost.
You did not mention the ballast management plan, I think this is what you're trying to explain.
My take is simple, Pilot is aboard after departing terminal and making a few minor turns in the channel, he should have alarm bells in his head.....tenderness when giving rudder commands, in a nutshell...he should have slow belled the 62° turn knowing the stability issues....all would have ended well, the pilot accsess hatch was open because he would be utilizing it shortly, I put it on the State Pilot for not having the awareness to not tempt fate
My issue with the pilot hatch is leaving it unattended.
It is a hard read on the tenderness as she was only doing 2 or 3 turns and his objective is also to get the ship out.
@@wgowshipping those ships are notorious for stability issues, used to see em taking 2-3° lists just steering across Gatun lake in The Panama Canal, i still think a reduction in speed would have averted the whole screwup
@@jamestaylor9603 I entirely agree with you and that should have been communicated by the Chief Mate to the Master. Or the Master should have known if he had the accurate readings on the GM of the ship.
There is a lot blame here and not solely the Chief Mate.
I just retired from the M/M's. This happened approx. 40+ mi's north from me. I was curious on what A.B.S. & C.G. had to say about this. It sounds like improper watch standing on the C/M's part. I wonder will he have his Capt.'s license revoked? Thanks for the video Great info.
Get Dan Gryder on for his opinion of the NTSB. Aside from the pollition, I understand why they made the decision to cut the ship up. Trying to refloat it in one piece probably would have been an impossible task.
Seconding the recommendation to check out the "Probable Cause: Dan Gryder" channel. You might want to subscribe and then keep an eye out for upcoming videos related specifically to his opinion of the NTSB. His channel was recently hacked and a number of videos were removed, including those which explore the reasons behind his opinions about the NTSB. He has talked about planning to release more along those lines and I think you will find them interesting when he does.
Dan's opinions aren't worth warm spit.
I disagree that the NTSB is better on aircraft accidents. Great analysis confirming what you speculated before.
I like your critical comments, Sal. Excellent!
There were rumours that the ship was not ballasted properly since they wanted to ballast when in open water, to use cleaner ocean water rather than "dirtier" water from the docking area. If so, this is criminal. Also, shouldn't the stability/ballast calculations have been checked by a second person to verify their accuracy before sailing was permitted? Furthermore, didn't a sister ship capsize in similar fashion not that long before the Golden Ray capsized, indicating a fundamental problem with either the design of the ships OR the company operating them?
There needs to be more than one person, even if they are off the vessel looking at the data.
Looking at just the report, there was no problem with the ships design, just the operating of it. You can see that it is stable just with the eye alone. (If you know what you are looking at).
Saw a report, not able to independently verify however, that this wreck removal is going to wind up being costlier than the COSTA CONCORDIA removal, which is certainly a red flag. My experience is on tankers and containerships, and not recent anymore, but even I know that these ships are a higher risk for this type of incident in both intact and damage stability scenarios - there is a significant history of them doing it. So its definitely doesn't pay to cut corners.
The NTSB was "influenced" by someone, probably a well-connected prominent Washington attorney hired by the company. Thats how things work nowadays, folks. Would explain matters not asked, not explained, witnesses not called, etc.
How fast was the Golden Ray planned to be going when the Pilot was due to come off the vessel?
It depends on weather conditions and the style of pilot boat they use, but 10 to 12 knots is not unusual.
Thank you for doing such a good job reporting this information.
Thanks for watching!
Good point about ship took off ballast and didn't adjust it after
The NTSB may well have missed some things here, but I think a big part of what you are responding to is the "voice" of a NTSB report. There is a certain scope and attitude. The feeling is perhaps a bit like: "You good sirs are officers and gentlemen, and it goes without saying that you have nothing but the best interests of the public at heart, but... " I believe it is standard that every report begins with a statement that this is *not* about assigning blame, it is about making sure that this does not happen again. When they say that the accident is because the first mate (?) did not properly perform the stability analysis, they leave unsaid "of course nobody would sail if they knew there ship was going to capsize". I do not know what they did and did not know, but in what reports I have seen where perhaps someone was "cutting corners" (where *we* would assume self-interest), the attitude is more like, they ask "why did you do this unsafe thing?" If the person says "I thought it was OK", then that's a "training problem". If it is company policy, then they tell the company they had not done proper safety analysis when the made this policy.
I don't know the history of this voice, but I think it is related to the "no fault" attitude toward anonymous reporting of near-accidents. The idea seems to be to focus on the immediate causes of an incident because this is in some sense more actionable. Crew can be pushed to do unsafe things, but if they understand the risks better then they will likely be less unsafe, since they don't want to die. And if it is a company policy, then the company gets publicly told that it is an unsafe policy. At least within aviation, safety authorities around the world seem to pretty closely follow precedents set by the FAA, even though they don't officially have authority outside the country.
re. your remark about how the ballast info could be uploaded, and decisions could be monitored in that way. This is precisely what is now done in aviation. If you land too fast, you get a phone call a few days later asking what happened. I don't understand the details of how this information is used, who has access to it for what purposes, but the emphasis seems to be on avoiding the problem. Even if the company wants to cheat, if the regulator forces them to institute this monitoring system, then cheating gets hard, because it is all a matter of record. Nobody has to tell the officers and gentleman that they are liars and cheats.
You seemed puzzled about the loading plan not including weight info. I wonder if the real purpose of the loading plan is mainly a matter of "seating", getting the vehicles located where they can be loaded and unloaded at the right port without having to shuffle things around. It would seem from the report that the crews do not worry about this very much. I don't know how that works, but perhaps cars are similar enough in weight, and it all averages out.
Great indepth report Sal.
Thank You Sir, really good wrap up. Question: How do insurance companys act in a case like this?
Henrik...that is the big question. There is two insurance groups, H&M (Hull & Machinery) and P&I (Protection & Indemnity). This would fall under H&M although P&I would have to pay for some under General Average. It depends on the ultimate cost which is over $800M now.
@@wgowshipping Ok thank you for quick response.
What I'm aiming at is that a correctly loaded and barlasted vessel will not turn over!
So this is no acident but the result of bad seamanship, incompetent personnel, neglecting rules, taking chances, bad company management, .......
And the insurance companies still pays the bill?
Sir: NTSB investigations, or Casualty Investigations as per IMO MSC Circulars, are based on facts and observations, not fictional assumptions such as the ones you have made.
Human factors include errors by the crew -including negligence-. Malice doesn't not need to be involved.
PS. Pilots are not caddies. That is an extremely disrespectful analogy.
The fiction here is that the NTSB failed to ascertain why the ship did not load ballast when even with the inaccurate readings inputted by the Chief Mate had a GM below the permitted amount.
They failed to ask why the ballast tanks with water in them were only half full and allowed for free surface to add to the issue.
Also, I know and work with many pilots. The analogy is meant to convey that pilots assist but do not relieve the master of their ultimate responsibility.
My statements are based on the material report and my discussing this issue with two chief mates currently serving on board car carriers but did not want to become public.
Very Interesting real world prospective. If taking on ballast (dirty river water) is issue- why do ports not make clean water ballast available to take on and off as needed?
As a layman I would ask, if the 1st mate has the ability to fudge these calculations for whatever motive, does he then also have the ability to dictate the speed and other factors during the relative maneuvers? seems like a huge gamble if he does not, and the master assumes that all is in order. an so we have this incident.
It depends if the CM has the conn. But during the exit of the port that would be in the hands of the pilot and Master.
Golden Ray salvage completed this week. So it took almost 2 years to finish the review, and how long to salvage? Yes, I am coming over from MMs TH-cam.
So to get into the Dunkirk GA port 1500 tons of ballast was pumped out and when leaving the Dunkirk port, at no time was the 1500 tons of ballast pumped back into the Golden Ray. Then exiting that bay turning 68 degrees it rolled over.
You note the NTSB report stated the chief mate input the ballast mathematical numbers manually and without anyone else checking his numbers! The ballast numbers manually input were incorrect!
You seem to imply this was all done intentionally, obviously not to roll the ship but for saving money by cutting corners reducing the need to overwork the onboard ballast treatment center, treating brown mucky bay water and instead waiting to get into the ocean to ballast with pumped in blue cleaner ocean water .
You note there was no need to manually input ballast numbers and instead they could be read electronically automatically by turning on the electronic panel to feed the onboard computer. Why wasn’t this done? because it would kick in automatically that more ballast would be pumped in while in the bay, causing an expense treating this mucky filthy water at a later time.
From reading some of the comments by more knowledgeable people on this topic, this seems to be a common practice. As a foreign vessel little can be policed to get to the bottom of what really happened and the whole expensive blunder is swept under the NTSB regulatory carpet. We live in a time of little accountability.
Great video and thanks for making these seafaring capsized details so easily understood by anyone not a mariner.
Thanks for the content
The door tag will not give the weight. It gives the max weight fully loaded. Full fuel passengers and payload. A 1500 truck may have a weight sticker for 7800lbs but weigh around 5600 with a driver and fuel but no real payload.
The door sticker may not, but every manufacturer publishes the empty weigh. In my country empty weight is required on the registration and licence documents.
How do you leave the door by the water open? HOW??!
Could the accident have been avoided by steering differently or going slower?
You are probability right. But if you think that the NTSB isn't doing a good job on the field that you are deeply familiar with, what makes you think they do a better job on everything else you don't feel you already deeply understand?
Wow Kevin...I am now more worried.
A while back, Dan did an analysis of the qualifications of the NTSB board, and found a total lack of any member with a pilot's license. Hence the continual moped jokes.
@@SteamCrane The NTSB board isn't supposed to be experts on navigating ships around hurricanes or ballasting vessels or design of flight control software, or bridge design methodologies, or why planes might not rotate after V1. They are there to ensure that they have experts, the experts do their job and that they keep the big picture in mind.
@@k53847 ...but the results are BS.
We in Savannah. This is a serious foul up. A lot goings...
Take a look at probable cause about the NTSB.
Sounds so much like the Hoegh Osaka leaving Southampton (UK) in 2015
My guess was that they had a uncomfortable rolling than they preferred on the way in, and tried to correct it by increasing the period by making her more tender - thus did a manual calculation to get the metacentric height 'close enough' to a go condition to pass a sniff test, and entered those faked numbers to the computer. It may also have been compromised by taking on cargo - and leaving a previously filled ballast tank now with a free surface. It sounds like an approved, but inappropriate action to suit some or all of the crew's comfort to me... at the expense of safety.