Was it the captain's fault, as many said? Or did the company, the Coast Guard and the American Bureau of Shipping all have a hand on the helm of the SS El Faro as she steered too close to Hurricane Joaquin? This is an examination of a tragedy that has been well-researched and investigated -- heroically so at times -- by the United States Coast Guard and the National Transportation Safety Board. Three very well-done books have been published. All of these efforts produced detailed recommendations and observations and all are publicly available. I commend them to you. My effort touches on the broad sweep and events of the tragedy and investigation, but if you want the detailed story of the final voyage of the ship, you're better off with the other books. My main goal here is to show how the SS El Faro fit into a larger system and culture -- one that I have been covering off and on as a journalist and author for 38 years. It's this system, I feel, that will result in another SS El Faro someday unless it is reformed. Another note on style. My preference in non-fiction is "narrative." In other words, whenever I can, I tell a story and show what is happening; I prefer that to "telling" the reader, because I think "showing" is more readily absorbed. Humans learn through stories. Story telling rather than a lecture better illustrates the emotions at play here, as well as the moods, culture and vibe of the ship and the industry. This does not mean I take a pure poetic license. The dialogue quoted here is real, not made up. The material is factual.