The sinking of MS Estonia: Case Reopened Part VII

[Andy_Ross]

Deleted

 

[Andy_Ross]

And this was considered reasonably acceptable for the vessel type at the time. EPIRBs are secondary distress signals for large vessels that are presumed to have a large, well-trained crew and will have at least several minutes' survivability in the case of accident. Further, such vessels are not considered as susceptible to foundering as smaller vessels, and so the scope of accident contemplated for both primary and secondary distress signalling does not involve immersion.



This is why training is emphasized by designers and regulators, but often skimped on by operators. We rely heavily on rote checklists and second-nature behavior that can be addressed only by rigorous testing that translates into operational overhead for an operator. But to the point, we have seen on a number of occasions that the crews of ships are susceptible to "survival mode" when faced with actual emergencies.



The phenomenon of de minimis reasoning in an emergency is something I covered in the classes I taught. Case studies include Three Mile Island and Apollo 13.

There is also the issue that you can't recall a mayday. This is why the initial distress call in many contexts is often pan-pan. You can always upgrade a pan-pan to a mayday, or you can also withdraw a pan-pan. But once you say mayday, rescue efforts are set in motion. Since operators can be fined for improper use of distress calls, there is some reticence among operators to signal one until it's painfully evident that it's needed.

There is another paradoxical phenomenon associated with redundancy: initially it tends to be less reliable than singular solutions. Absent training and specific, pedantic requirements, redundancy can offer a false sense of security. In this case, operators may believe they don't need to operate the EPIRBs because the distress call was made by the primary method. Or one operator may believe the other one turned on the EPIRBs. This is one of the things we look for in accident analysis.

Rescinding the exemption for vessels under the 1974 SOLAS certificate puts the redundancy where it should be, and where it's less susceptible to the redundancy paradox.

Also, if a particular crew member on a watch is detailed off as being responsible for a task, it might not get done if that person is not available or busy with other duties.
This can be mitigated with suitable procedures and training.

 

[JayUtah]

Also, if a particular crew member on a watch is detailed off as being responsible for a task, it might not get done if that person is not available or busy with other duties.
This can be mitigated with suitable procedures and training.

I thoroughly agree, and it's not always done correctly.

The theory goes that if one person is given a task, she knows it's her task to perform under all circumstances, and she can assume that if she doesn't do it, it doesn't get done. When circumstances suggest adding more people responsible for a task, it's not always made clear how the sequence of responsibility proceeds. If you simply say that a group of people collectively are responsible for a task without setting a protocol for verification, that's when you fall into the redundancy trap. That's when one person believes that when things go pear-shaped, and she can't perform a task, one of the other people assigned to it will take up the slack. This fails to happen a lot of the time, leading to the redundancy paradox.

The classic example of doing it right is commercial passenger jet crews. There must always be two pilots, and the protocol for who does what and when is rigidly followed. The classic counter example is Apollo 10, where the two pilots did not have a thorough protocol for operating the lunar module: uncoordinated control inputs resulted in an aborted landing approach. The same pilot flew on Apollo 17, and established a control authority protocol by drawing a chalk line down the lunar module control panel.

Conversely, in the common case where one operator has several tasks it's not uncommon for contingency checklists to have many corner cases in which operation and verification do not occur. And this is beside the point of improvised responses. If there are n tasks and m operators in the loop for any one task, the training matrix is n⨯m, which is usually more than anyone outside the military is able to train on. Militaries are astoundingly competent at managing high-risk technologies. Passenger cruise lines, less so.

 

[Here_to_learn]

He put his radio receiver on 1 to block out the interference.

What is your source for, this, and exactly how did he express it?

Because what you describe is not possible on a Marine VHF set, and only confirms that you have no idea on what you are posting about. I have a good idea on what he probably did, and that action does not block out interference. Instead it opens the set so that you can hear traffic with a low S/N ratio.

 

[Vixen]

I thoroughly agree, and it's not always done correctly.

The theory goes that if one person is given a task, she knows it's her task to perform under all circumstances, and she can assume that if she doesn't do it, it doesn't get done. When circumstances suggest adding more people responsible for a task, it's not always made clear how the sequence of responsibility proceeds. If you simply say that a group of people collectively are responsible for a task without setting a protocol for verification, that's when you fall into the redundancy trap. That's when one person believes that when things go pear-shaped, and she can't perform a task, one of the other people assigned to it will take up the slack. This fails to happen a lot of the time, leading to the redundancy paradox.

The classic example of doing it right is commercial passenger jet crews. There must always be two pilots, and the protocol for who does what and when is rigidly followed. The classic counter example is Apollo 10, where the two pilots did not have a thorough protocol for operating the lunar module: uncoordinated control inputs resulted in an aborted landing approach. The same pilot flew on Apollo 17, and established a control authority protocol by drawing a chalk line down the lunar module control panel.

Conversely, in the common case where one operator has several tasks it's not uncommon for contingency checklists to have many corner cases in which operation and verification do not occur. And this is beside the point of improvised responses. If there are n tasks and m operators in the loop for any one task, the training matrix is n⨯m, which is usually more than anyone outside the military is able to train on. Militaries are astoundingly competent at managing high-risk technologies. Passenger cruise lines, less so.

The way you find out whether something gets done is by performance measures. The best way to find out if something has been done is to measure it.

That is how the JAIC knows for a fact that the M/V Estonia EPIRB's had been tested the week before the disaster. One or both of the ships radio electricians had to sign off a log they had tested them and that they were fit for purpose, i.e. ready to emit a signal to COSPAR-SARSAT on being submerged in up to 4m of water, as released by the HRU and on arising to the surface of the water.

So we know that there were the prescribed two EPIRB's one ither side of the bridge, as per CHAPTER III 1988 IMO.

A manually-activated EPIRB should be kept indoors of the boat and within easy reach to switch on by the user.

The MV Estonia EPIRB's were of the prescribed free-float automatic tyoe. Rockwater confirm they found the cages on either side of the bridge empty and managed to recover one of the hydrostatic release units. Only automatic EPIRB's would be fitted with an HRU.

End of.

 

[lobosrul5]

The way you find out whether something gets done is by performance measures. The best way to find out if something has been done is to measure it.

That is how the JAIC knows for a fact that the M/V Estonia EPIRB's had been tested the week before the disaster. One or both of the ships radio electricians had to sign off a log they had tested them and that they were fit for purpose, i.e. ready to emit a signal to COSPAR-SARSAT on being submerged in up to 4m of water, as released by the HRU and on arising to the surface of the water.

So we know that there were the prescribed two EPIRB's one ither side of the bridge, as per CHAPTER III 1988 IMO.

A manually-activated EPIRB should be kept indoors of the boat and within easy reach to switch on by the user.

The MV Estonia EPIRB's were of the prescribed free-float automatic tyoe. Rockwater confirm they found the cages on either side of the bridge empty and managed to recover one of the hydrostatic release units. Only automatic EPIRB's would be fitted with an HRU.
End of.

I think even you know that, that statement is a bald-face lie.

 

[JayUtah]

The way you find out whether something gets done is by performance measures.

Performance measures based on training rarely match performance measured in actual contingency scenarios.

That is how the JAIC knows for a fact that the M/V Estonia EPIRB's had been tested the week before the disaster. One or both of the ships radio electricians had to sign off a log they had tested them...

Correct. The testing of the EPIRBs is not in question.

../and that they were fit for purpose, i.e. ready to emit a signal to COSPAR-SARSAT on being submerged in up to 4m of water...

No. That's you tacking your ignorance onto the question.

So we know that there were the prescribed two EPIRB's one ither side of the bridge, as per CHAPTER III 1988 IMO.

Asked and answered.

A manually-activated EPIRB should be kept indoors of the boat and within easy reach to switch on by the user.

Not if the regulation requires it to be kept in an HRU regardless of its activation method.

The MV Estonia EPIRB's were of the prescribed free-float automatic type.

Asked and answered.

Rockwater confirm they found the cages on either side of the bridge empty and managed to recover one of the hydrostatic release units.

Irrelevant.

Only automatic EPIRB's would be fitted with an HRU.

False.

End of.

End of what? Literally everyone understands this but you. The tempest you're trying to manufacture literally goes away if we relax the assumption that you know what you're talking about.

 

[GlennB]

<bilge snipped>

End of.

Do I hear the sound of little feet being stamped? Are you discombobulated?

 

[JayUtah]

Do I hear the sound of little feet being stamped? Are you discombobulated?

Those feet stamping are Vixen being six steps ahead of everyone else. Six steps in the wrong direction, mind you. But apparently Vixen is the only one who knows the right answer on every question anyone could ever ask.

 

[Steve]

What is your source for, this, and exactly how did he express it?

Because what you describe is not possible on a Marine VHF set, and only confirms that you have no idea on what you are posting about. I have a good idea on what he probably did, and that action does not block out interference. Instead it opens the set so that you can hear traffic with a low S/N ratio.

"Sources? We ain't got no sources. We don't need no sources. I don't have to show you any stinkin' sources!" /old movie quotes.

 

[Andy_Ross]

A manually-activated EPIRB should be kept indoors of the boat and within easy reach to switch on by the user.
End of.

You just made that up. What absolute ****.

 

[LondonJohn]

Never heard that phrase? It's commonplace among "master business strategists", by all accounts.....

 

[Steve]

You just made that up. What absolute ****.

No. When Vixen invented manually-activated EPIRBs that is exactly what she wrote in the manual. Too bad nobody read it.

 

[LondonJohn]

And countless other facts, large and small. Her performance in this thread simply repeats the same lies over and over, peppered with inflammatory rhetoric. Her call to repentance for others' alleged dishonesty is only one ironic example of the latter.



They are right to do so. Many regulatory bodies walk a fine line. The FAA, for example, has a dual mission to both promote and regulate air travel, but its regulatory mission is not always first for takeoff. In contrast, the IMO is focused on safety but relies upon treaties and is therefore hobbled by diplomacy. The fine line there lies between needful regulation and the sustainability of member nations. The IMO is most effective when most if not all seafaring nations are able to participate. If regulations are too onerous or fleeting, members will withdraw and the mission fails.

Grandfathering across the fine line has more diplomatic and political value than safety value. The mandate for all ships to have hydrostatically released buoys, but a selective requirement for the buoys to be immersion-activated is exactly the kind of regulatory stupidity that those of us governed by this labyrinth detest. You get the stupid situation of having manual-only buoys in automatic-release brackets.

Just because it's stupid doesn't mean it doesn't happen. This is where conspiracy theorists argue from a fantasy world in which everything makes common sense. Yes, common sense tells you that if you have float-free buoys in hydrostatically-operated brackets, they should also be immersion-activated. A couple of $1,500 EPIRBs should be a miniscule expense to someone operating a multimillion-markka ship, right? Well, no, that's not at all how owners and operators think. Instead, it's a $3,000 (two EPIRBs) expense for a half dozen ships in the fleet, so $18,000, in a budget bursting with mandatory repairs, upgrades, and improvements.

"Are we required to upgrade these devices?"
"Not yet, not if we stay with the 1974 certificate."
"The ones we have still work, right? In case of emergency, they'll still bring help?"
"Yes, they're manual-only, but they still work and the crews are trained on them."
"And we already paid $X,000 to upgrade the holders, which are now up to regulation and will still hold these models, right?"
"Yes, we're fully compliant."
"Great!"

And with that conversation, the $18,000 fleet-wide EPIRB upgrade gets stricken as part of some hypothetical need to trim, say, $250,000 out of that year's upgrade budget. At this level of decision-making, it's an exorbitant expense for what is perceived as only a marginal increase in safety that's not required, but falls under "would be good to have someday, but not today."

The CEO of a shipping line will definitely be having dinner occasionally with the country's IMO representative. And a periodic topic of conversation will be the ongoing expense for keeping up with new regulations.

"See, Miko, it seems like we just get our ships up to standard, and the next year we have to refit everything we refit last year because of new regulation changes. We borrowed $3 million last year to accomplish the refit, and now we'll have to borrow another $3 million to do next year's refit before we even have time to earn enough fares to pay off the prior loan. We need to be able to operate at a reasonable level of safety for a time, not the bleeding edge all the time."

Grandfathering is an all-too-common balance between safety and economy. And you can't just write off economy. Engineering isn't about total reliability and total safety. It's about acceptable reliability and safety for the affordable price. If it costs $10,000 per person to cross the Baltic Sea, travel simply won't happen. It happens today at an affordable price because we accept that risk.

Now on the other hand, when we write accident reports we get to be sanctimonious. The JAIC is right to call the grandfather exemption foolish, because in hindsight it was foolish. A ship sank and many people died in part because of delays in distress response, including EPIRB operation. Investigative bodies have the privilege of identifying flaws and making recommendations regardless of cost. The very fact that we're writing an accident report means the risk-cost-benefit analysis was off-kilter in a way that matters to the traveling public.

Carriers ride the fine line because we want them to—right up to the point where the ship sinks or the plane crashes or the train derails. Then we wag our fingers at them and tell them to get back across the line. It's not that carriers are evil. We just don't know where that line is at any given moment, either as carriers or as designers and builders. When an accident happens, some of us are tasked with redrawing the line using 20/20 hindsight. And yes, we get to call out such things as complacency and laxity in regulation. But we get to invoke what the law calls res ipsa loquitur—"the thing speaks for itself." The fact that a plane is now a smoking crater, or a ship is now a reef, means that something went wrong that shouldn't have, and it needs to be found and fixed. After the fact, we get to be sanctimonious. Before it, economics is still a factor.

Outstanding post, sir. Explanatory, illuminating, authoritative, and right on the money (pun intended).

 

[LondonJohn]

Am I right in thinking that the EPIRBs on board the Estonia were automatically activated upon immersion in water?


*Ducks and covers*

 

[Axxman300]

The EPIRB thing simply speaks to the level of attention to detail, or the lack thereof, by the MS Estonia's crew. Which in turn adds subtext to why the ship is on the bottom of the ocean today with over 800 people inside. If you think about, in all of the reports, official, and investigative, at no point has a crew member come forward with an account of voicing concerns about the safety of the ship. No stories of crew members demanding to be reassigned, or quitting due to unsafe practices and attitudes by the command and crew. This suggests one of two things: none of the crew were aware of deficiencies in regards to safety issues, or they knew and didn't care.

This was an accident. All the elements aligned at the right time for the most dramatic impact. This can be said for most accidents of this type. The other factor that only stands out from an oceanography standpoint is that the passenger eye-witness accounts suggest a rogue wave in the midst of a demanding storm. And rogue waves have done damage to other ships, and sunk a few. In those cases everything can be ship-shape, and still end in disaster.

Instead, what we have are people looking for something other than fate to blame, and a shipping company desperate not to be found liable in anyway working in concert to create a mythology to counter the truth, and facts of the matter. Even now after the two-year investigation of the wreck, the mythologists are already publicly changing gears to find fault with the second investigation (which they demanded take place), instead of putting away their Ouija boards, and calling it a day.

 

[W.D.Clinger]

End of.

End of what? Literally everyone understands this but you. The tempest you're trying to manufacture literally goes away if we relax the assumption that you know what you're talking about .

To be fair, hardly anyone is making that assumption.

Which explains why the manufactured tempest is a bit of hot air that isn't going anywhere.

 

[phiwum]

Survivors report the list commenced at 01:00 and Mikael Oun's travel alarm clock is on display at a museum as having stopped at that time, when the list caused it to crash to the floor.



Capt Thornroos' account differs from the JAIC and the coast guards. He states:



EFD





He put his radio receiver on 1 to block out the interference.

I thought that the Coast Guard station had recordings of the Mayday. How do you explain that?

Sent from my SM-G991U using Tapatalk

 

[JayUtah]

To be fair, hardly anyone is making that assumption.

Yes, I immediately considered that I should have said, "Relax the premise." This multi-hundred-page odyssey has exactly one source: Vixen's willful ignorance. There is no legitimate controversy over why MS Estonia sank.

 

[zooterkin]

To return to this, prompted by a mention in another thread.

That is incorrect. Professor Ida Westermann, Head of Metallurgy at a Norwegian University found indisputable evidence that the deformation she observed in her testing of a section of the bow visor could not have been caused by the 'pressure of pounding waves' or 'the striking of the bow visor against the car ramp', as claimed by the JAIC in its conclusions, and they were only guessing, anyway.

Likewise British Naval explosives expert, Robin Braidwood did recognise a British hexacomposite explosive device, which had not gone off, when he saw it on a video.

Call them liars all you want but at least they have provided considered documentary evidence. Your claim, "No signs or evidence of explosives were found" is unsubstantiated.

Re. the highlighted. This is the first post I can find on the forum that even uses the word 'hexacomposite'. Vixen, would you care to explain what it means and where Robin Braidwood said he recognised such a device?

I can find no mentions of 'hexacomposite' via google, either, apart from your posts on this forum, so it looks like something you have invented, but I'm sure you can explain.