Dick Trauma posted:

Too bad the Church didn't include "only use wooden goblets with a flared base" as part of the catechism.

nikitakhrushchev posted:

One of the most striking things to me about aviation and space flight disasters is the way thinking can break down in such a way as to doom the flight. Like in, I think it was AF447, where the copilot kept pushing a brake down and nobody realized in time. There's always that human element that can go awry.

System Metternich posted:

Proofreading is for the bourgeoisie

()

Basebf555 posted:

It must be a horrific feeling to be the co-pilot who's loving up, and the pilot comes in and tells you you're loving up, and then realizing that its too late and you just killed everyone.

RCarr posted:

It seems like the normal law / alternate law thing is a pretty flawed system. Obviously, I know nothing about aviation, but shouldn't there be a giant light in the cockpit that lets the pilots know which one they are in?

quote:

The upset recovery training was included in the aircraft operator’s training manual. The aircraft operator advised the KNKT that the flight crew had not [undergone] the upset recovery training on the Airbus A320, and this referred to FCTM Operational Philosophy: ‘The effectiveness of fly-by-wire architecture, and the existence of control laws, eliminates the need for upset recovery maneuvers to be trained on protected Airbus aircraft.’

Basebf555 posted:

It must be a horrific feeling to be the co-pilot who's loving up, and the pilot comes in and tells you you're loving up, and then realizing that its too late and you just killed everyone.

quote:

02:13:40 (Robert) Climb... climb... climb... climb...
02:13:40 (Bonin) But I've had the stick back the whole time!

[At last, Bonin tells the others the crucial fact whose import he has so grievously failed to understand himself.]

02:13:42 (Captain) No, no, no… Don’t climb… no, no.
02:13:43 (Robert) Descend, then… Give me the controls… Give me the controls!

[Bonin yields the controls, and Robert finally puts the nose down. The plane begins to regain speed. But it is still descending at a precipitous angle. As they near 2000 feet, the aircraft's sensors detect the fast-approaching surface and trigger a new alarm. There is no time left to build up speed by pushing the plane's nose forward into a dive. At any rate, without warning his colleagues, Bonin once again takes back the controls and pulls his side stick all the way back.]

02:14:23 (Robert) drat it, we’re going to crash… This can’t be happening!
02:14:25 (Bonin) But what’s happening?
02:14:27 (Captain) Ten degrees of pitch…

Exactly 1.4 seconds later, the cockpit voice recorder stops.

Skarsnik posted:

I really want to be interested in your post but holy poo poo go back and edit ( or just post it again ), its not just the odd typo

quote:

Michael Creigh, a native of Ireland, aged forty-eight years, applied at the Montreal General Hospital, in December, 1862, for surgical assistance. He stated that he had a foreign body in his private parts, which caused him great pain. He was in a semi-flexed position, and said he could not straighten himself, as the body was piercing the back of his bladder.

He was immediately stripped of trousers, and placed on a table with knees bent up. On being interrogated, he said he had been a victim of self-pollution for many years, and that the ordinary manner of practising it had lost its effect upon him, and that he had taken to the introduction of a foreign body into the urethra in preference.

He said he was a stevedore by occupation, and had always a large pencil with him, and this instrument was what he was in the habit of using. This pencil had slipt from his fingers, and had gone into the bladder, so that it was pressing against the back of the viscus, whilst the upper end was coming through under the scrotum. Upon examination a hard substance was found presenting itself as the patient had stated. The usual forceps was introduced to withdraw the pencil with the assistance of the finger in the rectum. but the head of the pencil being rounded, it always slipt off, and the neck of the bladder spasmodically contracted around it. It was impossible to move the body.

The patient was placed in the position for lithotomy, the head of the pencil presented itself nearly midway between the anus and scrotum. An incision was made through the raphe…
…into the membranous part of the urethra, when the head was seized, with a little difficulty, by a pair of strong forceps, and the entire body extracted. It required some force to withdraw it. There was slight hemorrhage from the transverse artery of the perineum, which required a ligature to control it. The after treatment was the same as for a case of lithotomy, and the patient left the hospital in a week quite well, with a strong determination not to try any more “pencilling by the way.”

The pencil was six and a quarter inches long, a quarter of an inch in diameter, and called in trade “No. 3 Rehback’s Express Pencil.”

quote:

Mr. Cock, at Guy’s, has recently had more than one ordinary case of lithotomy under his care; and Mr. Callaway recently was called to a very singular case.

A boy, somewhat silly in his manner, was admitted, presenting the ludicrous condition of having a common shoehorn, tied to a piece of whipcord, hanging from his urethra! The boy had been pulling at the cord, reminding one in some way of a celebrated lexicographer’s definition of a fishing rod…

…but something which he could not or would not describe was at the opposite end, fixed in the bladder. The boy, it is believed, had been reading some bad books, and had made a long cylinder of the substance known to tailors as French chalk, which he had been pushing into the urethra, till probably, at the triangular ligament, it was drawn by the perineal muscles into the bladder.

Be this as it may, Mr. Callaway had to cut down in lithotomy form, and then extracted a mass of French chalk, not unlike the little finger of one’s hand. We mention the case as one of the varieties or ‘vagaries’ of hospital surgery.

quote:

A few months ago I was called in great haste to a young gentleman, who was in a most ludicrous yet painful condition. I found, on examination, a bottle, holding about a pint, with a short neck and small mouth, firmly attached to his body by the penis, which was drawn through the neck and projected into the bottle, being swollen and purple. The bottle, which was a white one, with a ground-glass stopper and perfectly transparent, had an opening of three fourths of an inch in diameter only: and the penis being much swollen rendered its extraction utterly impossible. The patient was greatly frightened, and so urgent for its removal that he would give me no account of its getting into its present novel situation, but implored me to liberate it instantly, as the pain was intense and the mental anguish and fright intolerable.

Seeing no hopes of getting an explanation in his present predicament, and after endeavoring to pull the penis out with my fingers, without success, I seized a large knife lying on the table, and with the back of it I struck a blow on the neck of the bottle, shivering it to atoms and liberating the penis in an instant, much to the delight of the terrified youth. The glans penis was enormously swollen and black, as was the prepuce; both were vesicated [blistered], as though scalding water or fire had been applied to them. He complained of smarting and pain in the penis, after the bottle was removed; and inflammation, swelling and discoloration continued for a number of days, but by scarification and cold applications, subsided; yet not without great apprehensions on the part of the patient, and a good degree of real pain in the penis.

The reader is probably anxious to know, by this time, how a penis, belonging to a live man, found its way into so unusual a place as the mouth of a bottle.

I was extremely curious myself; but the fright and perturbation of the patient’s mind, and his apprehensions of losing his penis entirely, either by the burn, swelling, inflammation, or by my cutting it off to get it out of the bottle, all came upon him at once and overwhelmed him with fear.

Now for the explanation. A bottle in which some potassium had been kept in naphtha, and which had been used up in experiments, was standing in his room; and wishing to urinate without leaving his room, he pulled out the glass stopper and applied his penis to its mouth. The first jet of urine was followed by an explosive sound and flash of fire, and quick as thought the penis was drawn into the bottle with a force and tenacity which held it as firmly as if in a vice. The burning of the potassium created a vacuum instantaneously, and the soft yielding tissue of the penis effectually excluding the air, the bottle acted like a huge cupping glass to this novel portion of the system. The small size of the mouth of the bottle compressed the veins, while the arteries continued to pour their blood into the glans, prepuce, etc. From this cause, and the rarefied air in the bottle, the parts swelled and puffed up to an enormous size.

How much potassium was in the bottle at the time is not known, but it is probable that but a few grains were left, and those broken off from some of the larger globules, and so small as to have escaped the man’s observation. I was anxious to test the matter (though not with the same instruments which the patient had done)…
…and for that purpose took a few small particles of potassium, mixed with about, a tea-spoonful of naphtha, and placed them in a pint bottle. Then I introduced some urine with a dash, while the end of one of my fingers was inserted into the mouth of the bottle, but not so tightly as to completely close it, and the result was a loud explosion like a percussion cap, and the finger was drawn forcibly into the bottle and held there strongly — thus verifying, in some degree, this highly interesting philosophical experiment, which so frightened my friend and patient.

The novelty of this accident is my apology for spending so many words in reporting it, while its ludicrous character will, perhaps, excite a smile; but it was anything but a joke at the time to the poor sufferer, who imagined in his fright that if his penis was not already ruined, breaking the bottle to liberate it would endanger its integrity by the broken spicules cutting or lacerating the parts.

quote:

James Bishop, an apprentice to a ship-carpenter in Great Yarmouth, about 19 years of age, had violent pains in the lower part of the abdomen, for 6 or 7 months; it did not appear to be any species of the colic; he sometimes made bloody urine, which induced Mr. P. to believe it might be a stone in the bladder. He was very little relieved by physic; at length a hard tumour appeared in the left buttock, on or near the glutaeus maximus, 2 or 3 inches from the verge of the anus, a little sloping upwards. A short time after he voided purulent matter by the anus, every day for some time.

Shortly after, the prongs of a fork appeared through the orifice of the sore, above half an inch beyond the skin. As soon as the prongs appeared, his violent pains ceased; I divided the flesh between the prongs, according to the best of my judgment; and after that made a circular incision about the prongs and so with a strong pair of pincers extracted it, not without great difficulty, handle and all entire; the end of the handle was besmeared with the excrement, when drawn out.
It is 6 inches and a half long, a large pocketfork; the handle ivory, but is dyed of a very dark brown colour; the iron part is very black and smooth, but not rusty.

A relation of his, a Gentleman in this neighbourhood, who sent him to be under my care, the Reverend Mr Gregory Clark, Rector of Blundeston, on whom, in a great measure, his dependence is, threatened never to look upon him more, unless he would give him an account how it came; and he told him, that, being costive, he put the fork up his fundament, thinking by that means to help himself, but unfortunately it slipped up so far, that he could not recover it again.

PS He says he had no trouble or pain, till a month, or more, after it was put up.

quote:

He had been suffering from an attack of piles, and having been informed that the disease could be cured by introducing the neck of a well-greased bottle containing some hot spirits of turpentine, he undertook to prove the remedy. But unfortunately, using nothing larger than a half pint flask, and having, as I suppose, a more than ordinarily capacious outlet to the alimentary canal, the flask slipped in, and the sphincter closed upon it.

Here is a dilemma—a man with a half pint flask in his rectum seeks relief; and what is to be done?

Notwithstanding the case borders a little upon the ridiculous, it became, to me, a subject of most serious and anxious concern. At length, however, I resolved upon a plan, and accordingly went to a blacksmith and had a pair of forceps made somewhat after the fashion of the obstetrical instrument, with blades about seven inches long, by about three-fourths of an inch wide, and handles eight or ten inches long. These being prepared, and the blades well greased, I introduced a blade at a time so as to inclose the bottle, locked the instrument, and commenced my efforts at extraction. But the blunt end, or bottom of the bottle presenting, I soon satisfied myself that it would be no easy task to effect its removal. At length, by the force of my efforts, I smashed the flask in fragments.

Having no further use for my forceps, I laid them aside and set myself carefully to work, removing it, a piece at a time, with my fingers. This I completely accomplished after laboring faithfully for about three hours.

On the 29th of January, 1847, I was called to see the same patient, and informed that a similar mishap had befallen him, the body now introduced being a beet. I made an examination, and could trace with the finger the large end of a beet of such dimensions as to cause the utmost astonishment; and to increase the difficulties of the case, it had been retained more than 48 hours, the patient having entertained the intention of dying like a hero, without disclosing his condition; from which determination, however, the intensity of his sufferings forced him to depart.

There was now a good deal of tumefaction and tenderness about the anus; and very great tenderness of the abdomen generally—vomiting had set in. I again introduced my forceps, but with great difficulty, on account of the tumefaction and soreness of the parts, and soon found that I could not make the necessary extractive efforts without having my forceps slip off: the patient was also exceedingly irritable, and could not endure the necessary force.

I now took my forceps to the smith, had the width of the blades reduced one-fourth, and the points turned in so as to form a hook, obtained two or three assistants, and returned to the novel operation. Having premised a free bleeding and the hot bath, so as to obtain a good degree of relaxation, I administered 35 drops of the tincture of opium, and having placed my patient on his knees and strapped him down tightly over some chairs, I again introduced my forceps, and quickly succeeded in bringing away a beet nearly seven inches in length, and in its largest diameter about three and a half inches.

It had evidently been selected by my patient on account of its size, in order that it might be impossible for it to be taken in; and feeling thus secure, he had introduced the small end, and pressed down upon it with his whole weight. I now administered injections, and laxative doses, and restricted my patient to a low diet for two or three days, when he again resumed his employment.

quote:

Some students had formed the plan of playing a practical joke on a prostitute; they determined to push into her anus a frozen pig’s tail.
They cut the hairs very short in order to make them sharper and rougher, then dipped it in oil, and forcibly introduced it into the woman’s anus, with the exception of a portion three fingers’ breadth in length, which remained outside. Several attempts were made to extract it, but, as it could only be withdrawn against the hairs, the bristles entered against the mucous membrane, and gave rise to excruciating pain. In order to relieve it, various oily remedies were given by the mouth, and the attempt was made to dilate the anus with a speculum in order to extract the tail without violence, but it was unsuccessful.

The consequences of this ‘joke’ were predictable and serious: the poor woman developed severe symptoms including violent vomiting, constipation, a high fever and abdominal pain. Marchetti – who came from a family of eminent physicians; this may have been Pietro or one of his sons – was summoned on the sixth day of her illness.

This physician, having been informed of what had happened, invented a very simple and ingenious device. He took a hollow reed, one end of which he prepared so that he could easily introduce it into the anus, and completely inclosed the pig’s tail in this reed, in order to withdraw it without pain. For this purpose he attached to the tail, by the end which projected from the anus, a stout wax thread which he passed into the reed. With one hand he pushed this form of canula into the rectum, and held the cord in the other, to prevent the tail being pushed in still further. He succeeded in completely inclosing the tail, and promptly relieved the patient.

quote:

In the evening of the 1st of March, 1848, a young man, very respectable in appearance, solicited Dr. Parker’s aid for his father, whom he had brought to the hospital. With many expressions, indicative of his sense of shame and mortification, he related that Loo, his father, then sixty years of age, had spent the preceding night in one of the ‘flower-boats,’ or floating brothels, on the river, with a prostitute. Under the insane excitement or intoxication produced by the combined influence of drinking spirituous liquors and smoking opium, the lecherous sufferer, in mischievous frolic, forced a glass goblet—size: diameter of brim, 2 5/8 inches; height, 3 1/2 inches; diameter of base, 1 7/8 inches—into the vagina of the companion of his sports.


In the course of the night Loo fell into a state of unconsciousness, when the woman sought her revenge. She carefully insinuated the base of the goblet within his anus, and then placing the end of her opium-pipe—a cylinder about an inch in diameter, and a foot and a half in length—at the bottom of the goblet on the inside, suddenly pushed it into the rectum, entirely above the sphincter. Twenty-four hours had elapsed since its introduction. An angle of about a half inch of the rolled lip of the glass had been broken out by efforts made by friends to remove it.

On examination, the glass was found firmly fixed in its position; it was very difficult to pass the extremity of the finger beyond its lip, betwixt its outside and the rectum. In Dr. Parker’s opinion, it was impossible to extract it entire: and, therefore, though anticipating difficulty and danger in the operation, he determined to break it down. By means of forceps, such as are used by obstetricians in breaking up the foetal cranium,

...commencing on the side nearest the pubis, he broke up the goblet, and extracted it piece by piece, carefully guarding the parts by folds of cotton cloth as he proceeded, and removing the small sharp fragments which fell with a teaspoon. After the bowl, or bell portion was removed, the most difficult part of the operation remained to be performed, for the hemorrhage was free, and the base of the goblet, with the sharp points of the sessile stem, resulting from the fracture, was high up in the rectum, and firmly embraced in a transverse position. Assisted by the bearing down of the patient,

the edge of the base was reached by the point of a finger, and with difficulty turned edgewise, guarding against fractured points by pledgets [cushions of cloth]; then, by pressing the smooth side, or bottom of the glass, against the rectum, it was at last extracted. Remaining fragments were sought for, and the intestine thoroughly washed out. To arrest the hemorrhage, which was considerable, strong solutions of sulphate of copper and of alum were injected, and temporarily confined in the rectum, by pressing a sponge against the anus. For a time the bleeding ceased; but during the night several ounces of coagulated blood were evacuated; afterwards, there was no more hemorrhage.


The operation occupied an hour and a half. An opiate was administered, and the patient placed in bed. The general treatment consisted in rest, laxatives, and light diet; the rectum was occasionally injected with tepid water, and solutions of nitrate of silver. On the fourteenth day the case was discharged cured.

...A young man, native of Canton, applied to Dr. Parker for relief. He had been married about eight months. On the nuptial night, he met with insurmountable difficulty in his attempt to establish sexual intercourse with his bride, and in an effort, on that occasion, sustained a severe, and most probably, irreparable injury, which caused great pain.

Since that night, erection of the penis is limited to about a half an inch of its root, the extremity of the organ, with its glans, hanging flaccid. On examination, a well-defined, transverse space, through the corpora cavernosa, about a half inch from the pubis, the site of fracture, was found to separate the penis into two parts.

No attempt was made to remedy this serious misfortune.

quote:

Dr. Nottingham brought forward a case of extraordinary wound of the penis. He said it was more properly a wound of the penis received in an extraordinary way.

A gentleman, after intercourse with his wife, observed haemorrhage, and an incised wound of the penis. It appeared that his wife had been using a glass syringe some days before.

On examination, Dr. Nottingham found a piece of glass behind the uterus fixed at one point. He made use of a four-barred speculum to open out the vagina, and removed the piece of glass with forceps. The woman was unconscious of its presence. He shewed the fragment, which was very thin and sharp; and also the syringe from which it had become detached. In another case, he had found several pieces of glass in the vagina. These glass perforated syringes are very thin and dangerous, and he always recommended a Higginson’s syringe and porcelain tube.


Mr. Denton had met with a case in which, during intercourse, the husband met with an alarming accident. A stem pessary… …which the female was wearing had become inverted, and the stem, projecting into the vagina, had entered the man’s urethra and caused great pain and great haemorrhage. Mr. Higginson said that some pessaries, when the stems are short, are liable to turn round, and also to drop out entirely.

System Metternich posted:

I went back and holy poo poo, I should just stop posting in a foreign language when tired, sorry. I hope it's more readable now (no guarantees though, I'm still/again pretty tired )

Improbable Lobster posted:

If you're gonna put things in your dick please use an appropriate, sterilized tool.

Nckdictator posted:

An angle of about a half inch of the rolled lip of the glass had been broken out by efforts made by friends to remove it.

The Snoo posted:

true friends

Solice Kirsk posted:

I think there's maybe 3 friends of mine that I would be OK fishing something out of their dick hole for them.

Sulla-Marius 88 posted:

everybody just take a moment and think about how many of your male friends' weiners you'd touch

i got to about 20 before i remembered i'm a registered sex offender

Sulla-Marius 88 posted:

everybody just take a moment and think about how many of your male friends' weiners you'd touch

i got to about 20 before i remembered i'm a registered sex offender

quote:

The operator put Davidson on hold and then the line went dead. Captain John Lawrence, the shipping company’s designated person on call, had received a similar voicemail from Davidson just minutes before and was trying in vain to reconnect with his colleague at sea. Seventeen minutes later, three automated distress signals from the El Faro triggered a massive Coast Guard search. After flying and sailing for eight days over 183,000 square miles around the ship’s last known position, the effort turned up an oil slick, a debris field, and a person so battered as to be unrecognizable floating in a survival suit.

When news broke of the vessel’s disappearance, people wanted to know how a modern American ship as big as Boston’s Hancock Building could sink without a single survivor. Why did the captain steer directly into the path of a hurricane? Why did the engines fail? Who’s responsible? Marine experts pointed to El Faro’s advanced age, or the company’s alleged greed, or the captain’s supposed arrogance in single-mindedly pursuing what became his deadly route.

In November 2015, a remote-controlled deep sea explorer launched from Woods Hole, Massachusetts, plunged 15,000 feet below the Caribbean Sea to photograph El Faro’s bruised, twisted hull. The ship’s bridge had been violently torn from the boat, and lay half a mile away on the ocean floor.

A federal investigation—four weeks of hearings held three months apart in Jacksonville, Florida—was jointly conducted by the U.S. Coast Guard and the National Transportation Safety Board. The proceedings produced copious testimony from former crew members, weather experts, shipping professionals, and shipping company executives. But no clear answers. In August 2016, another deep sea explorer retrieved the ship’s voice data recorder, which provided audio from the bridge, recorded in the hours leading up to the sinking. On it, you can hear the captain order the crew to abandon ship. It will likely take months before an official report is issued, and even then, we may never know exactly what happened on board El Faro that day.

In the spring of 2016, I became obsessed with shipping and the mystery of the El Faro. As I dove deeper into the tragedy, I began to ask a different question: What forces had brought that ship, and those sailors, including eight New Englanders—Michael Davidson, Danielle Randolph, Michael Holland, and Dylan Meklin from Maine; Jeffrey Mathias, Mariette Wright, and Keith Griffin from Massachusetts; Mitchell Kuflik from Connecticut—to that particular place at the particular moment, when a normally calm sea surged dozens of stories high, rolled the enormous vessel, unseated its cargo, and sent it to the deep?

Few Americans spend much time thinking about the industry, but cheap global shipping is the backbone of 21st-century life—it’s how we get $300 Chinese-made laptops and $12 Indian-made cotton T-shirts. About 90 percent of worldwide trade travels by sea. Sift through stacks of H&M jeans or walk the shoe aisles at T.J. Maxx and inhale the shipping container’s stale perfume; that’s the scent of commerce.

From an airplane, cargo ships look like steel alligators creeping up brown rivers, or barely visible specks cutting a perfect wake in the open sea. Dockside, they’re awesome and remote—with steel prows rising 30 feet up above the waterline, blue and red containers stacked eight stories high, and enormous propellers below.

The huge boats have their fans, too: With vessel-tracking websites like marinetraffic.com, you can follow ships as they travel around the globe. Each fuel-guzzling leviathan transporting millions of dollars of cargo, crewed by a handful of sailors watching the horizon for pirates or weather, appears on the screen as a small, colored blip. Hobbyist ship-spotters regularly upload time-stamped photos of the boats they’ve seen.

Throughout the spring, I streamed the hearings while driving or doing the dishes. I eavesdropped on chat rooms where professional seamen debated every revelation or news report. I researched the history of international shipping and the U.S. Merchant Marine, and visited the Maine Maritime Academy in Castine where young men and women were preparing to sail to Europe aboard the school’s training ship, the State of Maine. Their excitement was so contagious that I felt the pull to steam across the Atlantic with them. I wanted to experience the vastness of the ocean among confident young sailors and knowledgeable mariners. What was it like to be cut off from the world, focused only on the rigors of seafaring?

Instead, I sat for seven hours a day in the overly air-conditioned Jacksonville convention center-turned-courtroom listening to testimony. Relatives of those lost occupied the front rows facing the investigative panel, while TV crews and journalists watched from the back. Under oath, experts and mariners answered the panel’s questions with their backs to us; unable to see their faces, I could hear the concern or fear in their voices.

During breaks, many of us escaped the room’s chill to thaw in the Florida sun. That’s where I met Jill Jackson-d’Entremont, who’d recently moved from Philadelphia to Florida to be closer to her brother, Jack Jackson, an able seaman. When he was lost on the El Faro, Jill went to clean out his house and found his laundry still in the dryer.

Each lost sailor had stories he or she could not tell. To learn them, I needed to get closer to those they left behind. One chilly Sunday morning, I headed north to meet Deb Roberts.

Wilton, Maine, is landlocked and rural. To get there, take Route 4 out of Lewiston and follow the trail of used car dealerships, gun stores, and gas stations, over the Androscoggin River (just around the bend from the ailing Verso Paper Mill) to the foot of Wilson Lake, where a hard right gets you to the town of 2,000. Main Street’s offerings: a public library, bank, and post office. This is where Michael Holland lived—raised in nearby Jay, where he played high school football and got his first shotgun at age 16. This is lake and mountain country; the ocean seems worlds away.

Deb Roberts sent two sons to the Maine Maritime Academy. Michael was her oldest. After graduating in the spring of 2012, he went to work in the hot, humid, earplug-and-earmuffs-loud El Faro engine room to finance his life on land.

Southerners send their children to the military. New Englanders send their children to sea. Even before the American Revolution, a 12-year-old Maine boy could work in a ship’s galley and emerge a decade later as captain of his own vessel. After the revolution, the country depended on New England’s maritime prowess to feed its people and drive its economy. By the late 1700s, 90 percent of federal revenues came from the region’s merchants, so much so that when drafting the country’s first laws, Alexander Hamilton continually consulted with his Essex Junto—merchants who had opened up trade in places as far-flung as Guangzhou, the Pacific Northwest, and Fiji, and were now running large fleets from Salem, Newburyport, and Boston.

Like countless Maine boys before him, Michael had a plan: He’d bought a house in Wilton where he hoped to start a family, and once he owned the house outright, he would give up his life at sea for a job running a local power plant, just as his football coach had done. To Michael, friends came first, and he had plenty of them. “Michael would just be the first to volunteer, to try something crazy, to live life to the fullest,” Deb says, sitting across from me at her dining room table. “He had no idea that he just had 25 years to do it, but he lived as though he did.”

Behind her, a corner cupboard had been given over to “El Faro 33” gifts and mementos, which spilled onto the adjacent sideboard. On a shelf, a photo of Michael next to his first deer kill shows him long and lean—a boy who had suddenly found himself in a man’s body. In his Maine Maritime Academy graduation picture, you can see the wispy hint of a nascent mustache; his white officer’s uniform is snug in the middle where four years in a classroom softened the former athlete.

While Michael was at sea, Deb kept busy. She lobbied Maine legislators for a tax exemption for young mariners, worked as an administrator in the Jay school system, raised her other two children, and went at the weeds in her garden with a vengeance.

Michael preferred doing rather than pondering, just like his mother. “I never really got into a lot of conversations with Mike about the nitty-gritty details of shipping,” Deb says. “When he was home, it was about, What you making for dinner, mom? You got any leftovers? Did you go hunting? Did you go fishing? Did you catch any fish? Did you go to camp? You know, those types of things. We never talked shop, just the big things.”

But Deb noticed a change in Michael over his final summer. “We saw him more than we had seen him at all before,” she said. “You know, he lived 10 minutes away and we’d hardly ever see him. He was a single guy and when he was off on his Saturdays, he was off having fun.” Now that Michael had starting dating a nurse from Jay named Kelsea who worked in Farmington, Deb says, “I saw him settling down. I really did—I saw him becoming a grown-up.”

On Tuesday morning, September 15, Michael flew down to Jacksonville to join the crew of the El Faro for its final Puerto Rican run. Kelsea drove him to the Portland airport. The evening before he left, Deb brought him his favorite Greek pizza and reminded him to work on his Christmas list and text it to her so that she could start shopping for him. “Then I gave him a hug and a kiss, told him I loved him, and to have a great trip and I’d see him in November.”

Hurricane Joaquin began as a tropical depression in the Atlantic Ocean on September 28, the day before the El Faro left Jacksonville. The National Hurricane Center (NHC) predicted that as it intensified, the storm would get pulled north toward Atlantic City by a low-pressure system. This forecast proved dead wrong.

Even with all our technology, predicting the weather is still very much an art form. It begins with plugging raw data—temperature, barometric pressure, and regional systems—into dozens of computer models, which then generate various storm trajectories and strengths. The models rarely show identical storm paths and intensities, but often, a pattern emerges. Specialists analyze these patterns using their knowledge of past storms to guide them. By the time an NHC forecast is published, the data on which it’s based is at least six hours old.

More information increases accuracy. On land, data is in abundance. Every city, town, and airport across the country constantly records and reports minute changes. At sea, information is spottier; raw data comes from aircraft, ship-to-shore reporting, and weather balloons.

Storm intensity and trajectory are notoriously difficult to predict in the tropics. Due to winds, ocean temperatures, and changing currents, systems bounce around in confounding ways. Tom Downs—a professional meteorologist for Weather Bell, a private service that independently analyzes raw data and comments on the official forecasts—compares predicting tropical storms to trying to follow the end of an uncontrollable fire hose.

But on Tuesday, September 29, at 6 a.m., 15 hours before the El Faro left Jacksonville, Downs and his fellow Weather Bell analysts saw enough in their models to challenge the NHC forecast. They sent their clients a warning that the nation’s weather prediction was wrong: “While acknowledging this is tricky and not as obvious to me as Sandy,” the report said, “I am not just winging it … to be blunt it really has an ugly idea and is farther to the west than NHC. Given what is setting up in front of this (with the rain and easterly flow), this would be a disaster.”

That evening, Captain Eric Bryson, a ship’s pilot for Jacksonville Port, was waiting at home when the call came: The container ship El Faro was ready to leave port for its usual run south to Puerto Rico. At 7:30 p.m., he walked up the gangway of the ship to the top deck, then up several flights more to the bridge, where he met with the ship’s master, Michael Davidson. After a cup of coffee, Bryson stepped out into the night air on the port-side balcony. It was a balmy 80 degrees and calm under mostly cloudy skies. Looking up St. Johns River, Bryson prepared to guide the huge ship from the busy port east to the sea.

As a pilot, he was familiar with many of the El Faro’s crew, and had a special fondness for second mate Danielle Randolph, whom he’d known since she was a cadet working on the sister ship, El Morro, 12 years before. “On the bridge, she was always happy and friendly, and certainly all business,” he told me over the phone. That evening, he had heard Danielle on the walkie-talkie reviewing the cargo—294 cars, trucks, and trailers below deck, as well as 391 containers on its top deck. Remembering her, Bryson said, “She was uncommonly nice.”

—

Danielle spent her childhood in Rockland on the Penobscot Bay, determined to work on the ocean. Her passion started early: “I remember taking Danielle to kindergarten,” her mother Laurie Bobillot tells me, “and, you know, being my oldest, when I took her to school I was bawling my eyes out. I said to her, ‘Oh, I don’t want you to go to school.’ And Danielle goes, ‘Mama! I want go! I want to learn about the water!’ And I’m thinking, ‘Wow, this is just kind of weird.’”

In the summers, Danielle worked on the docks of Port Clyde for her aunt’s lobster business, and at the O’Hara Corporation—a fishing consortium and marina in Rockland. In the fall of her senior year at Rockland High School, Danielle only applied to the Maine Maritime Academy. That’s not how it works, her mother counseled her. You apply to a lot of schools and hold your breath. Danielle replied, “Mother, I’m going to MMA and that’s that.”

During her freshman year at the academy, Danielle phoned home to ask Laurie, a hairdresser, about hair loss. Was it normal to clog up the shower drain? Sure, she answered. Everyone sheds. When Laurie saw her daughter that spring, she was alarmed to discover that the stress of college had created bald patches in Danielle’s thick blonde locks. Her daughter shrugged it off. That was her way: She soldiered through.

Later, as a deck officer aboard container ships for TOTE Maritime, Danielle earned a reputation for holding her own as a cheerful, wisecracking, hard-working woman in the largely male industry. Still, she painted her stateroom pink and decorated the drab ships’ interiors for Easter and Christmas. As soon as she returned to Maine from each tour of duty, she’d shop for shoes and vintage ’50s dresses and snuggle with her calico cat, Spot.

For 10 years, she worked several stories above where engineers like Michael Holland labored in the engine room. She calculated loads, watched the weather, carried out orders. She was busy, and liked it that way.

But months-long stints away, hampered by limited cell and Internet service, made it difficult to maintain friendships. Danielle tried dating another sailor, but ended the relationship when she feared that settling down would ruin her career. When Danielle did reach out to her family while she was at sea, her messages were brief, impersonal, signed with a simple, brisk “-D.”

As a deck officer in a quasi-military industry, Danielle was trained to follow commands and avoid questioning her superiors. If she had concerns, her style was to walk away and think over the situation in private rather than confront it directly. Her stoic nature dovetailed well with the merchant marine, where life is about order, checklists, protocols. It’s an industry that attracts people who prefer solving problems with a wrench. Many mariners speak wistfully of the peace they find on board, where they are temporarily cut off from the noise of the world.

Though Danielle and her mother were close, she rarely talked about her life at sea. But lately, Danielle found herself serving under a steady churn of new masters. Some were hands-on—walking the decks and running daily drills to keep the crew up-to-date, alert, and engaged. Others disappeared into their staterooms and let the ship run itself, trusting their mates to be their eyes and ears.

Technology may have transformed the industry, but the captain still sets the culture aboard ship, just as he did in the 19th century. When Captain Ahab appears three days into the Pequod’s voyage, Melville writes: “Not a word he spoke; nor did his officers say aught to him; though by all their minutest gestures and expressions, they plainly showed the uneasy, if not painful, consciousness of being under a troubled master-eye.”

In May, TOTE had forced the resignation of Captain Jack Hearn, who’d served the company on and off for 28 years, 25 as master. Same with Captain Peter Villacampa, who had originally hired Danielle. Steven Schultz, the first mate on the El Faro’s final voyage, had only been with the company since August. There was barely time for each new captain to establish a rhythm, and there was even less job security. Nearly everyone was considered temporary.

In shipping, where you learn on the job, turnover can lead to a critical loss of knowledge. Some former El Faro crew members testified that they gleaned more about the aging boat they served by stumbling onto manuals on board. At the hearing, former Captain Hearn testified, “When I first transferred [to TOTE], there was tremendous experience on the specific run. After 10 years in the company moving up through the ranks, they knew their job, and they had a good mentoring program. By the time I was leaving [in 2014], that was changing. There was less experience both on the deck and in the engine room.”

Thousands of containers are lost at sea every year because they weren’t securely fastened. When a storm batters a boat, improperly tied cargo can crash onto the decks or slide around in the hold, compounding a ship’s roll. Hearn described using a tool for testing the “button”—the latch on the deck floor to which lashings were fixed. Later, a TOTE chief mate claimed that he’d never heard of the tool. Marine architects specified that El Faro’s cargo lashings should come from the button at a 45-degree angle, but some crew members said they didn’t know why that angle was important, or even how to test the lashings. Lashing tension—critical to its performance—was tested on board by feel. At sea, knowledge can be the difference between life and death.

Privately, Danielle hinted to her mother that she might be over it. The culture at TOTE had changed. She considered going back to school to study maritime law, or working on an oil rig.

On September 28, as she was preparing to fly down to Jacksonville for yet another tour on the El Faro, Danielle hemmed and hawed. It wasn’t like her. “She just felt that something wasn’t right,” Laurie says. “She didn’t want to go out shipping this past September, which was really weird. That was the first time ever, ever, that we heard the kid say, ‘I really don’t feel like going.’”

By 8:25 on the evening of September 29, the El Faro’s crew dropped the last of its lines and Captain Bryson guided the boat down the river. While he worked, he chatted with the ship’s master, Michael Davidson, and Jack Jackson. The men discussed the usual things, Bryson testified, including water traffic. They also touched on the tropical weather system building in the Atlantic. “I don’t recall what I saw or said,” Bryson told the investigative panel, “but Davidson said, ‘We’re just gonna go out and shoot under it.’ It was audible to everybody. No one reacted.”

An hour later, Bryson had navigated the El Faro to open water off the coast of Florida and prepared to disembark. He climbed down the side of the cargo ship by rope ladder and onto the pilot boat. At 9:30 p.m., the tug turned and headed back to land. Bryson would soon be the last person alive to have stood on the El Faro’s decks.

Through the night and into Wednesday, the tropical storm lumbered stubbornly along its southwestern path, just as Weather Bell predicted, slowing down and gaining intensity. By daybreak on September 30, the NHC declared the system a Category 1 hurricane named Joaquin, with a center located approximately 125 miles north of the Turks and Caicos Islands, but the forecast didn’t alter its predicted path. The El Faro sped down the Florida coast along its usual southeasterly route.

Captain Davidson had graduated from Maine Maritime Academy more than a decade before Danielle and Michael. Slim with salt-and-pepper hair, 53 years old, he had grown up on the Maine coast, where reminders of a glorious maritime past haunt every corner; where majestic inns are named for sea captains, like Camden’s Captain Swift Inn, Searsport’s Captain A.V. Nickels Inn, and the Captain Jefferds Inn in Kennebunkport; where official town welcome signs often depict schooners at full sail. Even the names—Searsport, Bucksport, Kennebunkport—speak to their nautical importance. This is where, for generations, boys went to sea to support their families through shipping, whaling, or fishing. Some never came back.

Davidson had spent his youth on the water. He’d mastered boats for Casco Bay Lines along the Maine coast and tankers in the Gulf of Mexico for ConocoPhillips before joining TOTE Maritime in 2013 to tag-team the Puerto Rican run. He made a good living, enough to maintain a 4,100-square-foot home on a cul-de-sac outside of Portland for his wife, Theresa, and his two athletic daughters. Now that the girls were in college, expenses were high. Fortunately, mastering container ships paid well, if you could get the work.

The day before, TOTE had offered Davidson time off. He declined, saying that he didn’t want to lose vacation days because he wanted to complete his shift in time for his 25th wedding anniversary.

The El Faro was 28 years older than the average cargo ship docking in American ports, ancient by international shipping standards. It had already lived several lives since it had been built in Pennsylvania during the Nixon administration. Originally christened the Puerto Rico, it was one of the last vessels produced by Sun Shipbuilding & Drydock Co. before the yard shut down. For nearly two decades, the ship carried cargo between San Juan and the East Coast of the U.S. for a Puerto Rican outfit. In 1991, Saltchuk, the Seattle-based parent company of TOTE, assumed ownership. The boat was conscripted to transport military cargo for two wars, and after being lengthened 90 feet in 1993, served in the rough Alaskan waters as the Northern Lights before traveling through the Panama Canal one last time to do the San Juan run again as the El Faro.

When news of the El Faro’s disappearance hit, a handful of Sun retirees reminisced on online message boards about building it. After the accident, Deb Roberts received a ship in a bottle handmade by a former Sun shipbuilder named John Glanfield, who said he had worked on the El Faro; he still felt a connection to the boat he’d help construct so many years ago.

The El Faro flew the American flag, and this is significant. One of the earliest acts of the U.S. government was to protect its maritime interests by forbidding foreign ships from participating in the country’s coastal trade. Some 200 years later, vessels hauling cargo between American cities must be domestically registered, built stateside, and crewed by citizens—members of the unions—following American labor laws. This legislation, known as the Jones Act, is designed to ensure that the U.S. isn’t forced to depend on a foreign entity for transporting goods, cargo, or troops during wartime. It also guarantees that America retains a certain level of nautical knowledge, should it ever find itself globally isolated.

And yet, the laws plague American shipping. Because U.S.-built vessels cost at least twice as much as those made in Asia, shipping companies often keep their woefully outdated boats longer than they should. It’s simply too expensive to upgrade their fleets. Many of the El Faro’s components, including its open lifeboats—just like those you’d find on the Titanic—were grandfathered in. Its power plant was also ailing. A compliance agent testified during the hearings that she wouldn’t bring its boiler up to full pressure because, well, it was old. In fact, one of two boilers on the El Faro’s steam plant had been shut down for inspection just before its fateful run, and was found to have significant problems. For this reason and others, the Coast Guard put the boat on a watch list; the El Faro was scheduled to be dry docked and overhauled in November before going back to Alaska.

At its peak, the American merchant marine moved 40 percent of the world’s trade. Then shippers began registering their boats in foreign countries to get around Jones Act requirements. Now the American merchant marine carries just one-half of one percent of global trade.

An ever-diminishing fleet means fewer job opportunities. Often, captains will take a first- or second-mate position on a boat to earn a paycheck. When oil prices dropped last year, petroleum companies reduced output, requiring fewer tankers and barges, and fewer crews to helm them. Mariners took another hit; good-paying jobs in the merchant marine protected by American labor laws are scarce indeed.

In this climate, Davidson was angling for a promotion. To comply with new emissions regulations in the Caribbean, TOTE had ordered a pair of liquid natural gas ships to replace its three aging vessels—El Morro, El Yunque, and El Faro—and Davidson hoped to captain one of these. He interviewed for the position in May, and was awaiting an answer when he arrived in Jacksonville in September. If Davidson didn’t get the promotion, he would probably follow the old boat through the Panama Canal back to Alaska, where it was slated to do the Northwest route once again. Michael Holland had already been told that he’d join the El Faro on its West Coast run in the spring of 2017. That was a long way from Maine.

In fact, TOTE wanted younger captains to helm its gleaming LNG Caribbean fleet. That makes sense, a veteran mariner tells me. “I’ve seen it’s much harder to train experienced captains for these vessels. What you need is video game experience. With non-feedback of a vessel, it’s more intuitive.” Besides, he adds, “knowing how to run an antique steam plant, not many captains can handle that kind of vessel. TOTE probably decided Davidson was more valuable in Alaska.” TOTE had identified its LNG captains, but probably hadn’t yet notified Davidson that he was not one of them.

On Wednesday afternoon, a day after the El Faro left port, former second mate Charles Baird was at home in South Portland watching the Weather Channel, and what he saw of the developing storm worried him. He texted his concerns to Davidson, who at that point was still close enough to the coast to get cell service. Like all deck officers, Baird knew that captains ultimately decide the route, but there’s often room for debate. Charlie Baird was navigating when Davidson took the same inland route during tropical storm Erika. A former first mate of the El Faro told me, “He was the one who’d convinced him to go inland.” He adds, “I challenged the masters all the time. I said, ‘Captain, you need to take the old Bahama channel.’ I said, ‘I’m putting it on you.’ You gotta threaten them.”

This time, on land and off-duty, Baird’s powers of influence were limited.

Davidson assured Baird that he was aware of the storm. Hurricanes were almost always pulled north at some point before hitting the Caribbean island chain, and a Category 4 hurricane hadn’t tracked through the Bahamas since 1866. But Joaquin was taking its time; its path defied the odds.

Later that day, an increasingly concerned Baird texted Davidson again: What was the captain’s plan for avoiding the storm? Davidson replied that he was heading along the normal route at full steam (20 knots), and would sail under the system. Baird followed up, reminding Davidson of the escape routes available to him—the channels cut between the islands that would get him to the lee side if he found himself in trouble.

Twelve hours later, Joaquin had inched southwest while escalating to category 3—a major hurricane with winds up to 129 miles per hour—while the El Faro continued on its collision course with the storm. Now the ship was east of the Bahamas as Joaquin closed in.

Captain Kevin Stith was steering El Faro’s sister ship back up to Jacksonville and didn’t like what he saw. He was on the other side of Joaquin, closer to Puerto Rico, when he sent an email via satellite to Davidson to report that he’d just recorded 100-mile-per-hour winds. He warned him about the errant NHC forecast, and asked about his plans.

In his testimony, Stith said that Davidson replied that he had been watching the storm, had altered his route southerly; he expected to be on the back side of the hurricane in a few hours. But GPS tracking later revealed that Davidson hadn’t changed course. In fact, Davidson continued full steam ahead on a straight southeastern course up to the end.

During the hearings, Davidson was described by those who worked with him as conscientious, if not hands-on. He wasn’t deeply involved with the minutiae of ship operations; like many captains, he relied on the other deck officers—like Danielle—to be his eyes and ears. Stith, who frequently served as Davidson’s first mate before becoming master of the El Yunque, testified,“I did not see him on deck often. Maybe twice during my time with him.”

But Davidson’s cautiousness may have gotten him into trouble with employers in the past. Some news services reported that he had lost his previous petroleum company job because he’d elected to have his ship towed to port when it developed steering problems. Just a month before his final voyage, he’d rerouted the El Faro to avoid Tropical Storm Erika. After the El Faro sunk, experienced mariners online often theorized that TOTE had chewed out Davidson for this longer voyage, which would have cost the company time and fuel.

Like any company, privately owned TOTE needed to be profitable. In the early 2000s, it played a cutthroat game of chicken with two other U.S.-flagged transportation companies to monopolize the Puerto Rican route, a major run protected by the Jones Act. In an attempt to bankrupt each other, the three carriers deliberately cut their shipping prices to unsustainable levels, and TOTE, along with Horizon, emerged victorious.

Eliminating the competition wasn’t enough to satisfy TOTE’s executives. In 2008, a federal antitrust investigation uncovered a years-long price-fixing scheme that the two surviving companies had worked out to ensure that each made money from the Puerto Rican route. Both companies pled guilty and paid millions of dollars in fines. High-level executives from TOTE and Horizon went to jail. TOTE restructured and cut management.

It’s possible that this history, combined with his need to impress TOTE, colored Davidson’s judgment when confronted with a storm as he steamed south in the Atlantic Ocean.

Then again, it’s possible that Davidson didn’t understand what he was up against. Stith says that when he served as Davidson’s first mate, he observed that the captain relied heavily on the Bon Voyage weather reporting system, a proprietary service paid for by TOTE. “I think that was probably his primary resource; it had been proven over the years reliable,” he said during his testimony. “I think in our conversations he had full faith in that Bon Voyage System.”

At the hearings, Bon Voyage representatives revealed that they generally repackaged National Weather Service forecasts, a data-inputting process that took several hours after the original report had been issued. Their predicted trajectory for Hurricane Joaquin, sent out on September 30, was as much as 21 hours old and 500 nautical miles off.

Slow-moving hurricanes are hell for mariners. With hours and hours of high winds and high seas, even the saltiest sailors get seasick as the enormous boat rolls, dips, rises, and slams down into the troughs of the waves. “It’s a big danger,” testified Hearn, who’d been at sea during Hurricane Sandy. “When you’re in the grip of heavy seas for a longer period of time than a front, my experience is, once you start fighting weather, cargo lashings come loose, and there’s the fatigue of crew. More than 24 hours of that, the cargo is in danger. It’s a hazard to go out because the cargo is heavy and could crush a person.”

One former El Faro first mate told me, “In rough conditions, the first thing you do is throw up. All get seasick, plus you’re scared, as the seas are breaking over, with the ship rolling, making its own wave.” He’d worked with Danielle—he was very fond of her, called her Dani—since she was a cadet. He was furious that the El Faro had taken her into the storm.

Joaquin was the slow and powerful storm all mariners dread. As the El Faro approached the Category 3 hurricane, Danielle and the crew tried to hang on as the vessel rose and fell, struggling to power through the high seas, straining cargo lashings to the point where some may have given way.

In huge swells, its massive propeller would have come in and out of the waves, putting excessive strain on the 40-year-old steam engine trying to keep pace. Hearn said, “If you’re slamming your stern out of the water, then the boat settles in the next trough of a wave. With the force of tonnage, it slams. It’s a pounding that could be catastrophic to the machinery.” Hearn describes a dire scene: “If your stern is slamming, you need to get into a head sea and reduce the speed. You risk [propeller] cavitation [a violent reduction in pressure that sends shock waves through the shaft] if the prop comes out of the water. You can feel the vibration when it does.”

Down in the engine room, Michael doubtless labored with his fellow engineers to keep the old plant running, trying not to get knocked into the hot steam pipes all around him as the ship’s prow rose and then plummeted. One problem they faced was clogging of the fuel lines. During voyages, chunks of the asphalt-like fuel, called bunk, settle to the bottom of the fuel tanks, and that sediment can get shaken free by the sea’s churn. It’s likely that someone in the engine room spent a sleepless night clearing the fuel-line filters dozens of times an hour. It might have been impossible to keep up. At some point near dawn, the engine went out.

Without propulsion, the enormous El Faro was at the mercy of an angry ocean, slammed by waves, thrashed by winds. It was particularly vulnerable because it had been designed with a broad lower deck that served as a parking lot for the cars and trucks it carried. If water got down there through an open hatch, or worse, through the enormous door cut in the hull for roll-on/roll-off loading, she could quickly destabilize and sink.

At 7 a.m. on October 1, Davidson made the emergency call to shore. His voice on the recording is eerily calm. They’d lost propulsion. They were at a 15-degree list. They were taking on water. There was a breach in the hull. About half an hour later, the black box recorded Davidson calling for his crew to abandon ship. But they had little chance for survival in open lifeboats and rafts.

On land, the Coast Guard and TOTE’s designated contact discussed the severity of the El Faro’s situation. No one at TOTE had been following the El Faro; Davidson’s emergency call came out of the blue. Plotting his position, the U.S. Coast Guard was alarmed to discover that the ship was just 20 miles from Joaquin’s eye. The storm would soon escalate to Category 4.

But that, and the automated distress calls, were the final messages from the El Faro.

In the wee hours of October 1, Danielle sent her mother an email. She’d told Laurie about harrowing hurricanes before, but always after the fact. This time, she wrote, “Don’t know if you’ve been hearing, we’re in really bad seas and really bad wind and heading straight for the hurricane.”

Then she wrote, “Give my love to everyone.”

“As soon as I read that, I knew we were done for,” Laurie tells me. “She never, ever, ever, ever would write Love, Danielle or anything like that. She wasn’t cold-hearted, she just had a really hard time saying—like I always had to finish the phone call, ‘Love you,’ and she’d say, ‘Love you, too.’ She would never be the one to generate the Love you, Mom type thing, you know what I mean? And for her to write on the email, ‘Give my love to everyone,’ I knew we were, we were, we were screwed.

“So when I got the phone call saying that they’d lost communication with the ship, ‘We’re sending people to look,’ I knew then and there that the ship went down. There was no doubt in my mind. I didn’t have to wait the seven drat days of them searching. I knew drat well that the ship went down.”

Strong and resilient, like so many parents of New England mariners before them, Michael Holland’s mom, Deb, and Laurie were among the first relatives of the lost crew to accept that the El Faro had been lost. During the agonizing week in Jacksonville while the Coast Guard combed the ocean for the survivors—and then any evidence of the enormous ship—they became the public face of maritime grief.

They worked with the Red Cross to set up a Facebook page with regular updates for anyone connected to the El Faro. They gave TV interviews to ensure that the human side of the tragedy wasn’t lost in its telling. Pictures of Michael, and Danielle—smiling in her crisp white uniform, her hair tucked beneath her hat—appeared everywhere.

After the final meeting in Florida, when relatives were told that the search was finished, Deb, her husband, and Kelsea navigated rush-hour traffic to get to the beach. Eight years before, Deb had driven to Castine to see Michael off before he sailed to Europe aboard the Maine Maritime Academy’s training ship. Now she was saying a different goodbye.

Holding her shoes, she walked to the water to be closer to her son. She said, “We had this beautiful moment on the beach where Kelsea and I just felt Michael.

“We went in the water, and obviously just lost it, and cried and hugged. I was crying, really crying hard,” she says. “And I was leaning down and then this huge wave came and got us soaking wet. And I was like, All right, Michael, I get it, I get it. OK, I’ll stop.”

Correction: Charlie Baird’s texts were sent to Captain Davidson on September 29 while the El Faro was still docked at Jacksonville.

Nckdictator posted:

Mercury Ballistic posted:

I used to work in the US Merchant Marine, that was a depressing read. Bad storms at sea can be scary, but that must have been terrifying to endure. Rough weather makes everything hard to accomplish, even eating is hard and sleeping is sometimes impossible from the rolling tossing you from your rack. To have the ship coming apart on you...yikes.

Hauki posted:

That's three more than I have. They can go to the loving hospital. I mean, I'll drive them but that's the extent of my involvement.

Nckdictator posted:

http://www.thomas-morris.uk

Have fun.

TapTheForwardAssist posted:

Dammit America, it's been 20 years and Jon-Benet Ramsey is still the 11th-most popular Wikipedia article for last month?

https://tools.wmflabs.org/topviews/?project=en.wikipedia.org&platform=all-access&date=last-month&excludes=

Guy Goodbody posted:

There were multiple documentaries about the case released recently

Mercury Ballistic posted:

I read somewhere that aviation risk can be visualized as several spinning discs, with a small offset hole in each one. Odds are you will miss the hole on one of them in the stack and the risk is minimal, but every now and then some poor bastard makes it through each hole and becomes another discussion in this thread.

quote:

For example, should there be maximum dose limits set in the system, so that doses several times higher than the published maximum are grayed out? UCSF decided not to set such limits. The reasoning at the time was that, in a teaching hospital with lots of patients with rare diseases, many of them on research protocols, such “overdoses” would usually be okay. A system with hundreds of “hard stops” would lead to many angry phone calls from frustrated doctors to pharmacists, demanding that they override the block.

When it came to pediatric patients, a second set of decisions had to be made concerning weight-based dosing. Since pediatric patients can range from a preemie weighing a couple of pounds to a morbidly obese adolescent, many pediatric medications are dosed based on weight, usually expressed in milligrams (of a medication) per kilogram (of body weight)(mg/kg). The committee overseeing our Epic implementation decided to require weight-based dosing for all children under 40 kilograms (about 88 pounds).

Another choice involved the translation of weight-based doses into pills. What if the computer calculated that a dose should be 120 mg (based on the child’s weight), but the only available pill was 100 mg? The decision: if the available medication was more than 5 percent off the calculated “correct” dose, then the pharmacist would contact the doctor to be sure she endorsed that conversion. After all, there might be cases in which a 10 or 20 percent disparity would be clinically meaningful and the doctor might rethink the order.

quote:

Do you spot the problem? Perhaps not, since it is hiding in the middle of this dense screen, which faithfully replicates the one seen by Lucca. Focus your attention on the line that begins with the number “160” inside a rectangular box.

Since doses can be ordered in either milligrams or milligrams per kilogram, the computer program needs to decide which one to use as the default setting. (Of course, it could leave the unit [mg versus mg/kg] box blank, forcing the doctor to make a choice every time, which would actually require that the physician stop and think about it, but few systems do that because of the large number of additional clicks it would generate.)

In UCSF’s version of Epic, the decision was made to have the screen default to milligrams per kilogram for all kids weighing less than 40 kilograms, in keeping with the weight-based dosing policy. That seemingly innocent decision meant that, in typing 160, Lucca was actually ordering 160 mg per kg — not one double-strength Septra, but 38½ of them.

Computer experts call this type of problem — when the same action can result in two very different results — a “mode error,” and it is especially problematic when the user is not focused on the mode (in this case, mg versus mg/kg) and the interface offers no obvious clues as to its current status. The most common mode error in day-to-day computing is activation of the caps lock key, which changes the output of all the other keys.

Computer designers try hard to avoid having any modes at all, but the caps lock key is a major convenience, and so it has survived. When you’re stuck with a mode problem, user-centered design principles dictate that the mode should be made obvious to the user. And so most computer manufacturers incorporate a light into the caps lock key to show when it’s activated, and they signal (with a little up-facing icon) that the caps lock key is on, thus explaining why you’re having no luck with your password.

Unfortunately, the Epic interface provides no guidance to alert the user that she is in mg/kg mode. I have shown a picture of the “160 mg/kg” screen to several thousand people — including many experienced physicians, pharmacists and medical computer experts — during lectures over the past year. “Please raise your hand,” I ask, “if you’re 100 percent sure you would have noticed the mg/kg setting.” (Had Lucca noticed it, she could have changed it to “mg” with two clicks.) Not a single hand has gone up.

quote:

Whether an automated system is monitoring the status of a nuclear power plant, a commercial jetliner, or your washing machine, perhaps the most challenging decisions revolve around what to do with alerts. On an average day at UCSF Medical Center, we prescribe about 12,000 medication doses, and order thousands more x-rays and lab tests. How should the doctor be informed if the computer thinks there is — or might be — a problem?

Because many academic medical centers installed Epic before 2012, UCSF had the advantage of learning from these early adopters. One near-universal recommendation was to be sparing with alerts, because every alert makes it less likely that people will pay attention to the next one.

Heeding this feedback, the medical center chose to disable thousands of the alerts built into the drug database system that the hospital had purchased along with Epic. Despite this decision, there were still tons of alerts. Of roughly 350,000 medication orders per month, pharmacists were receiving pop-up alerts on nearly half of them. Yes, you read that right: nearly half. The physicians were alerted less frequently — in the course of a month, they received only 17,000 alerts.

The alert problem was especially daunting in pediatrics. Given weight-based doses and the narrow therapeutic range for many medications, alerts fired on several of the 10 to 15 medications ordered by the doctors for the typical hospitalized youngster, and on the vast majority of orders processed by the pediatric pharmacists.

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Like many other physicians, pharmacists, and nurses, Jenny Lucca found alerts to be a constant nuisance. Even giving Tylenol to a feverish child every four hours triggered an alert that the dose was approaching the maximum allowed. Every training program has a “hidden curriculum” (the way things are actually done around here, as opposed to what the policies say or what the administrators told you during that interminable orientation). One of them — passed down from senior residents to the newbies — was, “Ignore all the alerts.”

While Lucca was slightly uncomfortable with that as a governing philosophy, she was convinced that most of the dozen or more alerts she received each day could be safely ignored, and she knew that doing so was the only way she could get her work done.

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In Levitt’s case, the decision to put her faith in the bar-coding system was not born of blind trust; since it had been installed a year earlier, the system had saved her, as it had all the nurses at UCSF, many times. Unlike the doctors’ and pharmacists’ prescribing alerts and the ICU cardiac monitors, with their high false positive rates, the nurses usually found their bar-code alerts to be correct and clinically meaningful. In fact, under the old paper-based process, the drug administration phase was often the scariest part of the medication ecosystem, since once the nurse believed he had the right medicine, there were no more barriers standing between him and an error — sometimes a fatal one.

Levitt trusted not just the bar-coding system, but UCSF’s entire system of medication safety. Such trust can itself be another hole in the Swiss cheese. While a safety system might look robust from the outside — with many independent checks — many errors pick up a perverse kind of momentum as they breach successive layers of protection. That is, toward the end of a complex process, people assume that, for a puzzling order to have gotten this far, it must have been okayed by the people and systems upstream. “I know that a doctor writes the prescription,” Levitt said. “The pharmacist always checks it... then it comes to me. And so I thought, it’s supposed to be like a triple-check system where I’m the last check. I trusted the other two checks.”

Levitt took the rings laden with medications to Pablo’s bedside. She scanned the first packet (each packet contained one tablet), and the bar-code machine indicated that this was only a fraction of the correct dose — the scanner was programmed to look for 38½ pills, not one. So she scanned each of the pills, one by one, like a supermarket checkout clerk processing more than three dozen identical grocery items.

Yet even after the bar-code system signaled its final approval, Levitt’s nagging sense that something might be wrong had not completely vanished. She turned to her young patient to ask him what he thought.

Pablo was accustomed to taking unusual medications, so he said that the Septra dose seemed okay. She handed the pills to her patient and he began to swallow them.

About six hours later, the teenager blacked out, his arms and legs began jerking, and he stopped breathing.