Final El Faro report recommends civil penalty action, safety changes

by: Stephanie Brown, NEWS 104.5 WOKV Updated:

EL FARO COVERAGE: Two years of articles, reports and video 

Two years after the cargo ship El Faro sank while transiting from Jacksonville to Puerto Rico, the Coast Guard Marine Board of Investigation that’s been working the tragedy has issued 31 safety recommendations, four administrative recommendations, and a recommendation to pursue civil penalties against the ship’s operator, TOTE Services.

"This tragedy never should have happened, and the findings in this report will serve as a roadmap for how we can prevent this kind of tragedy from happening again," Florida Senator Bill Nelson said in a statement. 

The Coast Guard said that the ship's conversion from roll-on/roll-off to container ship status added to the ship's lack of strength in bad weather.  

Action News Jax has obtained the Marine Board of Investigation’s Report of Investigation, which was released Saturday to families of the 33 who died in the sinking and will be made public Sunday morning.

The cargo ship was heavily loaded when it encountered Hurricane Joaquin off the Bahamas, and ultimately sank on October 1, 2015. While one set of remains were located during the active search and rescue mission, none of the 33 crew were ever recovered.

Investigators call the sinking “one of the worst maritime disasters in U.S. history."

The Report details at length the events of the sinking including the ship’s proximity to Hurricane Joaquin, the initial starboard list and intermittent flooding, the reduction of propulsion, the subsequent port list and loss of propulsion.

Among those top lines are contributing factors.

“TOTE did not ensure the safety of marine operations and failed to provide shore side nautical operations supports to its vessels,” says the Report.

Other factors identified by the investigators for the weather-related problems alone include El Faro’s Master didn’t “adequately” identify the risk of heavy weather; TOTE, the Master, and the ship’s officers were not aware of vessel vulnerabilities and operating limitations in heavy weather; the National Hurricane Center created and distributed tropical weather forecasts that were later shown to be inaccurate; and a duplicate track line was sent through one of El Faro’s weather softwares.

In the sequence that ultimately led to El Faro’s flooding, the Report says there was water that got on board not only through an open scuttle, but “likely through deteriorated internal structures and open cargo hold ventilation fire dampers, which compromised watertight integrity”; the crew’s “complacency, lack of training and procedures, and El Faro’s design” which hampered the crew’s ability to assess watertight integrity; the Master, Chief Mate, and crew not ensuring cargo was secured according to the ship’s Cargo Securing Manual; an incomplete survey compliance and material condition history of the vessel; a lack of procedures for storm avoidance and heavy weather plans that specifically contained engineering operating procedures, which contributed to the lack of propulsion.

There were problems highlighted as well with search and rescue operations and the ultimate call to abandon ship.

The Report says there was a lack of effective training by crew, as well as inadequate oversight by TOTE, the Coast Guard, and the American Bureau of Shipping, leading the crew to be unprepared to take the proper actions

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Additionally, investigators say the Master did not update shore-side contacts when the crew was preparing to abandon ship; the lifeboats were “completely inadequate” as an option for the crew in those weather conditions -- despite them meeting appropriate standards; and Coast Guard search and rescue operations failed to effectively mark the one deceased crew member who was located, meaning that person could not be later recovered or identified.

There were other unsafe actions and conditions identified in the Report that were not believed to contribute to the sinking, including a lack of specific requirements for review and approval of software for cargo loading and securing calculations; no regulations for stability software; and TOTE’s failure to notify the ship’s surveyor, the American Bureau of Shipping, about repairs to the ship’s lifeboat davits.

In their recommendation to pursue civil penalty against TOTE Services- El Faro’s operator- the MBI cites four key factors: a failure to comply with work-rest requirements, failure to comply with emergency procedures for special personnel by potentially not providing a safety orientation or basic safety training for the Polish riding crew, failure to notify the Coast Guard or ABS about repairs to El Faro’s lifeboat davits just ahead of the sinking boyage, and failure to notify the Coast Guard or ABS of repairs to the ship’s main propulsion boiler superheating piping in August.

There are 31 safety recommendations put forward in the Report.

Some of the recommendations aim at ship design and on board capabilities. The Board wants to require high water audio and visual alarms in cargo hold of dry cargo vessels, to install CCTV cameras to monitor unmanned spaces from the bridge, to review regulation and policy dealing with non-watertight openings that can’t be closed during ship operations, to require the periodic transmission of electronic records and data while a ship is at sea.

With potential lifesaving measures, the Board recommends the Commandant work to organize legislative change to eliminate open top gravity launched lifeboats for all oceangoing ships in the US commercial fleet, Voyage Data Recorder capsules be installed in a float-free arrangement, personal floatation devices on commercial vessels be outfitted with personal locator beacons, an anonymous safety reporting mechanism be set up for crew at sea.

Dealing with oversight, the Report recommends a change in regulation to require onboard and shoreside tracking of incremental vessel weight changes, regulation and approval of cargo loading software and stability software, explicit language showing the Coast Guard shares responsibility for assessing the adequacy of a company’s safety management system, increased oversight by the Coast Guard of third party surveys and a quality audit specific to the performance of those surveys.

Additionally, the Report recommends NOAA evaluate the effectiveness and responsiveness of its current forecast products, specifically in connection to storms that impact maritime operations but don’t make landfall. It also asks the Commandant to review the effectiveness of the Coast Guard credentialing process, add some new training courses.

There are also four administrative recommendations- acquire DNA samples for the purpose of identifying human remains, require VDRs to capture all communications on a ship’s internal telephone system, ensure the Coast Guard has full access and ability to use VDR data and audio, and require more documentation of deficiencies that are put to a class society for correction.

There are no recommendations of criminal prosecution, no recommendations of administrative or punitive action against the Coast Guard, and no recommendations of suspension or revocation action against any credentialed mariner.

The release of this report comes seven months after the final of three two-week MBI hearing sessions that were held in Jacksonville. The MBI, NTSB, and four “Parties in Interest”- TOTE, the American Bureau of Shipping, Herbert Engineering, and the widow of El Faro’s Captain -- questioned dozens of witnesses, which included personnel within the companies that owned and operated the vessel, those involved in the search and rescue, those who had previously done inspections, former crew members, and others.

The MBI’s Report was publicly released today, but privately disclosed to the families of the 33 people who died in the sinking on Saturday. Traditionally, the ROI isn’t released at this point, but rather given to the Commandant of the Coast Guard to consider first, and then made public along with the Commandant’s ordered action.

In this case, there was an exception made.

The MBI sought to make their ROI public at this stage both because they have aimed to be transparent through this process, and to allow the maritime industry to make some self corrections while the Commandant conducts his review- which has no set timeline.

One of the briefings took place in Poland, to accommodate the families of the five Polish riding crew members who were on board, performing work to convert the ship to the Alaskan trade.

All 33 families had filed wrongful death lawsuits against the owner and operator of the ship in federal court, but they have all since settled.

El Faro’s Voyage Data Recorder- or black box- was salvaged from the ocean floor after three separate missions to find and ultimately bring it up. From the VDR, investigators got conversations from the bridge in the 26 hours leading up to the sinking, along with other data that gave information about shipboard systems, the weather they were facing, and more.

The NTSB is issuing its own safety recommendations in December. They fully participated in the MBI hearings, but have also conducted their own interviews and issued their own factual reports.  

While those full recommendations are still to come, the Board actually already issued some recommendations dealing specifically with the safety of mariners at sea during hurricane season, saying they didn’t want to wait to get action started on potentially life saving measures.

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