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Coast Guard's El Faro report cites errors by captain, violations by TOTE

Oct 1, 2017 01:59 PM

The report says there was a lack of effective training for crew as well as inadequate oversight by the operator

El Faro sank on Oct. 1, 2015 during Hurricane Joaquin with the loss of all 33 crewmembers.

Courtesy NTSB

El Faro sank on Oct. 1, 2015 during Hurricane Joaquin with the loss of all 33 crewmembers.

The following are excerpts from the U.S. Coast Guard Marine Board of Investigation (MBI) report on the sinking of the cargo ship El Faro:

(WASHINGTON) — The loss of the U.S.-flagged cargo vessel El Faro, along with its 33-member crew, ranks as one of the worst maritime disasters in U.S. history, and resulted in the highest death toll from a U.S. commercial vessel sinking in almost 40 years. At the time of the sinking, El Faro was on a U.S. domestic voyage with a full load of containers and roll-on/roll-off cargo bound from Jacksonville, Fla., to San Juan, Puerto Rico. As El Faro departed port on Sept. 29, 2015, a tropical weather system that had formed east of the Bahamas Islands was rapidly intensifying in strength. The storm system evolved into Hurricane Joaquin and defied weather forecasts and standard Atlantic Basin hurricane tracking by traveling southwest. As various weather updates were received on board El Faro, the master directed the ship southward of the direct course to San Juan, which was the normal route.

The master’s southern deviation ultimately steered El Faro almost directly toward the strengthening hurricane. As El Faro began to encounter heavy seas and winds associated with the outer bands of Hurricane Joaquin, the vessel sustained a prolonged starboard list and began intermittently taking water into the interior of the ship. Shortly after 5:30 a.m. on the morning of Oct. 1, 2015, flooding was identified in one of the vessel's large cargo holds. At the same time, El Faro engineers were struggling to maintain propulsion as the list and motion of the vessel increased. After making a turn to shift the vessel’s list to port, in order to close an open scuttle, El Faro lost propulsion and began drifting beam to the hurricane force winds and seas. At approximately 7 a.m., without propulsion and with uncontrolled flooding, the master notified his company and signaled distress using El Faro's satellite distress communication system. Shortly after signaling distress, the master ordered abandon ship. The vessel, at the time, was near the eye of Hurricane Joaquin, which had strengthened to a Category 3 storm. Rescue assets began search operations, and included a U.S. Air National Guard hurricane tracking aircraft overflight of the vessel’s last known position. After hurricane conditions subsided, the Coast Guard commenced additional search operations, with assistance from commercial assets contracted by the vessel’s owner. The search located El Faro debris and one deceased crewmember. No survivors were located during these search and rescue operations.

Events and contributing factors

• TOTE did not ensure the safety of marine operations and failed to provide shore side nautical operations supports to its vessels.
• TOTE did not identify heavy weather as a risk in the safety management system (SMS) and the Coast Guard had not exercised its flag state authority to require identification of specific risks.
• TOTE and the master did not adequately identify the risk of heavy weather when preparing, evaluating, and approving the voyage plan prior to departure on the accident voyage.
• TOTE and the master and ship’s officers were not aware of vessel vulnerabilities and operating limitations in heavy weather conditions.
• TOTE did not provide the tools and protocols for accurate weather observations. The master and navigation crew did not adequately or accurately assess and report observed weather conditions.
• TOTE did not provide adequate support and oversight to the crew of El Faro during the accident voyage.
• The National Hurricane Center (NHC) created and distributed tropical weather forecasts for Tropical Storm and Hurricane Joaquin, which in later analysis proved to be inaccurate. Applied Weather Technologies used these inaccurate forecasts to create the Bon Voyage System (BVS) weather packages.
• The master and deck officers were not aware of the inherent latency in the BVS data when compared to the NHC forecasts. Additionally, the master and deck officers were not aware that they received one BVS data package with a redundant hurricane trackline.
• The master and deck officers relied primarily on graphical BVS weather forecasts rather than the most current NHC data received via SAT-C. El Faro crew did not take advantage of BVS’s tropical update feature and the ability to send BVS weather information directly to the bridge.
• The master did not effectively integrate the use of bridge resource management techniques during the accident voyage. Furthermore, the master of El Faro did not order a reduction in the speed or consider the limitations of the engineering plant as El Faro converged on a rapidly intensifying hurricane. This resulted in loss of propulsion, cargo shifting and flooding.
• The master of El Faro failed to carry out his responsibilities and duties as captain of the vessel between 8 p.m. on Sept. 30 and 4 a.m. on Oct. 1, 2015. Notably, the master failed to download the 11 p.m. BVS data package, and failed to act on reports from the 3/M and 2/M regarding the increased severity and narrowing of the closest point of approach to Hurricane Joaquin, and the suggested course changes to the south to increase their distance from the hurricane.
• The cumulative effects of anxiety, fatigue, and vessel motion from heavy weather degraded the crew’s decision making and physical performance of duties during the accident voyage.

• The increasing of El Faro’s load line drafts following the 2005-2006 conversion, combined with loading to near full capacity with minimal stability margin, increased the vessel’s vulnerability to flooding in heavy weather.
• Despite the apparent increase in cargo carrying capacity and increase load line draft which would result, the 2005-2006 conversion was not designated as a major conversion by the Coast Guard. Based on the available documentation, the final decision was based on the “Precedence Principle,” in that the Coast Guard had previously not designated similar conversions of sister vessels El Yunque and El Morro as major conversions.
• The crew’s complacency, lack of training and procedures, and El Faro’s design contributed to the crew’s failure to assess whether the vessel’s watertight integrity was compromised.
• El Faro’s conversion in 2005-2006, which converted outboard ballast tanks to fixed ballast, severely limited the vessel’s ability to improve stability at sea in the event of heavy weather or flooding.
• The master, C/M, and crew did not ensure that stevedores and longshoremen secured cargo in accordance with the Cargo Securing Manual, which contributed to ro-ro cargo breaking free.
• The practice of sailing with open cargo hold ventilation system fire dampers in accordance with SOLAS II-2, Regulation 20 and U.S. regulations created a downflooding vulnerability which is not adequately considered for the purposes of intact and damage stability, nor for the definitions of weathertight and watertight closures for the purpose of the applicable Load Line Convention.
• The Coast Guard practice of verbally passing deficiency information to the ACS surveyor without written documentation of the deficient condition resulted in an unknown or incomplete compliance and material condition history of El Faro.

• At 5:54 a.m. on Oct. 1, the master altered course to intentionally put the wind on the vessel’s starboard side to induce a port list and enable the C/M to access and close the Hold 3 starboard scuttle. This port list was exacerbated by his previous order to transfer ramp tank ballast to port, and resulted in a port list that was greater than the previous starboard list and a dynamic shifting of cargo and flood water.
• The port list, combined with the offset of the lube oil suction bellmouth 22 inches to starboard of centerline, resulted in the loss of lube oil suction and subsequent loss of propulsion at around 6 a.m.
• Coast Guard and ABS plan review for El Faro’s lube oil system did not consider the worst-case angle of inclination in combination with the full range of lube oil sump operating levels specified in the machinery operating manual. This led the crew to operate with a lube oil sump level within the operating range specified on the Coast Guard and ABS approved drawing, but below the 27-inch operating level, which was the only level reviewed by ABS.
• The master and C/E did not have a complete understanding of the vulnerabilities of the lube oil system design, specifically the offset suction. This lack of understanding hampered their ability to properly operate the ship in the prevailing conditions.
• TOTE’s lack of procedures for storm avoidance and vessel specific heavy weather plans containing engineering operating procedures for heavy weather contributed to the loss of propulsion.

• A lack of effective training and drills by crewmembers, and inadequate oversight by TOTE, Coast Guard and ABS, resulted in the crew and riding crewmembers being unprepared to undertake the proper actions required for surviving in an abandon-ship scenario.
• After 5:43 a.m. on Oct. 1, the master failed to recognize the magnitude of the threat presented by the flooding into the hold combined with the heavy weather conditions. The master did not take appropriate action commensurate with the emergent nature of the situation on board El Faro, including alerting the crew and making preparations for abandoning ship.
• When the master made the decision to abandon ship, approximately 10 minutes before the vessel sank, he did not make a final distress notification to shore to update his earlier report to TOTE’s designated person ashore that they were not abandoning ship. This delayed the Coast Guard’s awareness that El Faro was sinking and the crew was abandoning ship, and impacted the Coast Guard’s search and rescue operation.
• Although El Faro's open lifeboats met applicable standards (SOLAS 60), they were completely inadequate to be considered as an option for the crew to abandon ship in the prevailing conditions.
• The Coast Guard’s existing search and rescue equipment and procedures were unable to effectively mark and track a deceased El Faro crewmember for eventual recovery. As a result the crewmember remains missing and unidentified.

Evidence of acts subject to civil penalty

• Standards of Training, Certification and Watchkeeping (STCW) rest violations — On numerous occasions there were violations for the rest hours prescribed in STCW for deck officers serving on board El Faro, these violations were systemic and not addressed by TOTE.
• In particular there were three violations for the requirement contained in 46 U.S.C. § 8104 for a third mate on July 7, 2015 and July 14, 2015 and for a different third mate on Sept.1, 2015. This rest requirement is for deck officers to get a minimum of six hours rest in the 12 hours immediately before the vessel goes to sea.
• Furthermore there is evidence that the 3/M did not meet the six hours of uninterrupted rest (per 46 CFR § 15.1111) on the following dates: Aug. 5, 8, 22, and Sept. 5 based on the records that were provided by TOTE. The complete STCW work records for the accident voyage are not available due to the loss of El Faro.
• Potential violation of 46 U.S.C. § 8106(a)(4) — no safety orientation or Coast Guard-approved basic safety training (BST) for the Polish riding crew.
• Failure to notify the Coast Guard or ABS of repairs to primary lifesaving appliances that were conducted on Sept. 28 and 29, 2015, just prior to El Faro’s departure from Jacksonville on the accident voyage.
• Failure to notify the Coast Guard or ABS of repairs to El Faro’s main propulsion boiler superheating piping on Aug. 24, 2015.

Click here to read the complete report, including the board's safety recommendations.

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