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El Faro: NTSB report at a glance

Jan 31, 2018 01:56 PM

 
Key findings:

  • If the second deck access hatch (scuttle) had been fitted with a remote open/close indicator at a manned location, such as the bridge, the crew would have known it was open.
  • It is likely that the seawater piping below the waterline to the vessel’s emergency fire pump in cargo hold No. 3 was inadequately protected from impact.
  • All of the watertight and weathertight ventilation closures to the cargo holds most likely remained open throughout the sinking sequence.
  • If a damage control plan had been available and the crew trained in its use, the crew would have been better able to promptly plan for and address the flooding scenario encountered during the casualty.
  • El Faro’s captain did not use the most current weather information for decision-making.
  • The captain should have returned to the bridge after the second and third mates called him to gain a better awareness of the changing weather situation.
  • Had the deck officers more assertively stated their concerns, in accordance with effective bridge resource management principles, the captain’s situational awareness might have been improved.
  • TOTE failed to assess the risk posed by Hurricane Joaquin to El Faro.
  • Although there is no direct evidence that the company applied pressure regarding the vessel’s schedule, inherent pressure could have influenced the captain’s decision to continue on despite the weather.
  • The Coast Guard’s Alternate Compliance Program is not effective in ensuring that vessels meet safety standards. Many vessels enrolled in the program are likely to be operating in substandard condition.
  • The vessel’s open lifeboats would not have provided adequate protection even if they had been launched.


Key recommendations:

  • Propose to the International Maritime Organization (IMO) that all watertight access doors and access hatch covers normally closed at sea be provided with open/close indicators both on the bridge and locally.
  • Propose to the IMO to require that new cargo vessels be equipped with bilge high-level alarms in all cargo holds that send audible and visible indications to a manned location.
  • Require recurring bridge resource management training for all deck officers when renewing their credentials.
  • Require that all deck officers, at both operational and management levels, take a Coast Guard–approved meteorology course.
  • Require that open lifeboats on all U.S.-inspected vessels be replaced with enclosed lifeboats that meet current regulatory standards, and freefall lifeboats where practicable.
  • Require all personnel employed on vessels in coastal, Great Lakes and ocean service be provided with a personal locator beacon.
  • Require that all U.S. vessels carry 406-MHz emergency position indicating radio beacons (EPIRBs). Immediately discontinue the use of EPIRBs that are not GPS-enabled.
  • Conduct a complete review of the Alternate Compliance Program to assess its adequacy and effectiveness.
  • Review and implement training of Coast Guard inspectors and accredited classification society surveyors to ensure they are properly qualified and supported to perform effective, accurate and transparent vessel inspections.

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