Notable Investigations

​Sinking of US Cargo Vessel SS El Faro

On Thursday, October 1, 2015, the SS El Faro, a 40-year-old cargo ship owned by TOTE Maritime Puerto Rico and operated by TOTE Services, Inc., was on a regular route from Jacksonville, Florida, to San Juan, Puerto Rico, when it foundered and sank in the Atlantic Ocean about 40 nautical miles northeast of Acklins and Crooked Island, Bahamas. The ship had sailed directly into the path of Hurricane Joaquin, carrying a crew of 33, including 5 Polish contract repair workers. All those aboard perished in the sinking.

The NTSB'​​s accident investigation identified the following safety issues:

  • Captain's actions
  • Use of noncurrent weather information
  • Late decision to muster the crew
  • Ineffective bridge resource management
  • Inadequate company oversight
  • Company's safety management system
  • Flooding in the cargo holds
  • Loss of propulsion
  • Downflooding through ventilations closures
  • Need for a damage control plan
  • Lack of appropriate survival craft

The NTSB determined that the probable cause of the sinking of El Faro and the subsequent loss of life was the captain's insufficient action to avoid Hurricane Joaquin, his failure to use the most current weather information, and his late decision to muster the crew. Contributing to the sinking was ineffective bridge resource management on board El Faro, which included the captain's failure to adequately consider officers' suggestions. Also contributing to the sinking was the inadequacy of both TOTE's oversight and its safety management system. Further contributing factors to the loss of El Faro were flooding in a cargo hold from an undetected open watertight scuttle and damaged seawater piping; loss of propulsion due to low lube oil pressure to the main engine resulting from a sustained list; and subsequent downflooding through unsecured ventilation closures to the cargo holds. Also contributing to the loss of the vessel was the lack of an approved damage control plan that would have assisted the crew in recognizing the severity of the vessel's condition and in responding to the emergency. Contributing to the loss of life was the lack of appropriate survival craft for the conditions.

Marine Accident Report 17/01 includes details of the NTSB's investigation and recommendations issued as a result of the investigation. The NTSB also issued an Illustrated Digest of the Sinking of the US Cargo Vessel El Faro.

Sinking of Amphibious Passenger Vessel Stretch Duck 7

About 1908 central daylight time on July 19, 2018, the Stretch Duck 7, a 33-foot-long, modified World War II-era DUKW amphibious passenger vessel that was operated by Ripley Entertainment Inc., dba Ride The Ducks Branson, sank during a storm with heavy winds that moved rapidly on Table Rock Lake near Branson, Missouri. Of the 31 persons aboard, 17 fatalities resulted. More than 7 hours prior to the accident, the National Weather Service had issued a severe thunderstorm watch for the area, followed by a severe thunderstorm warning a minute before the vessel departed the passenger boarding facility.

The NTSB's accident investigation identified the following safety issues:

  • Company oversight
  • Engine compartment ventilation closures
  • Reserve buoyancy
  • Survivability
  • Coast Guard oversight

The NTSB determined that the probable cause of the sinking of the amphibious passenger vessel Stretch Duck 7 was Ripley Entertainment Inc. dba Ride The Ducks Branson's continued operation of waterborne tours after a severe thunderstorm warning was issued for Table Rock Lake, exposing the vessel to a derecho, which resulted in waves flooding through a non-weathertight air intake hatch on the bow. Contributing to the sinking was the Coast Guard's failure to require sufficient reserve buoyancy in amphibious vessels. Contributing to the loss of life was the Coast Guard's ineffective action to address emergency egress on amphibious passenger vessels with fixed canopies, such as the Stretch Duck 7, which impeded passenger escape.

Marine Accident Report 20/01 includes details of the NTSB's investigation and recommendations issued as a result of the investigation.

Contact of Crane Barge Mr Ervin, Pushed by Towing Vessel Kristin Alexis, with Sunshine Bridge

On October 12, 2018, about 0141 local time, the towing vessel Kristin Alexis was transiting with the crane barge Mr Ervin upbound on the Lower Mississippi River near St. James, Louisiana, when the crane struck the deck of the Sunshine Bridge while passing under the west channel span. No pollution or injuries to the six crewmembers on board the Kristin Alexis were reported. The bridge was completely closed to vehicular traffic for 49 days while repairs were made, which resulted in significant traffic impacts.

The NTSB's accident investigation identified the following safety issues:

  • Inadequate voyage planning
  • Lack of company oversight
  • National Oceanic and Atmospheric Administration bridge data and charts

The NTSB determined that the probable cause of the Mr Ervin crane barge striking the Sunshine Bridge was the inadequate voyage planning and watch turnover between the captain and pilot, resulting in the pilot transiting beneath the bridge's west span instead of its channel span. Contributing to the accident was the lack of company oversight. Also contributing to the accident was the charted information for the bridge used by the pilot, which did not reflect the actual vertical clearance of the west span.

Marine Accident Brief 20/29 includes details of the NTSB's investigation and recommendations issued as a result of the investigation.

Fire aboard Small Passenger Vessel Conception

About 0314 on September 2, 2019, the Coast Guard received a distress call from the Conception, a 75-foot-long small passenger vessel operated by Truth Aquatics, Inc. The vessel was anchored in Platts Harbor on the north side of Santa Cruz Island, 21.5 nautical miles south southwest of Santa Barbara, California, when it caught fire. Despite firefighting and search and rescue efforts, the vessel burned to the waterline and sank just after daybreak, and no survivors were found. Thirty-three passengers and one crewmember died.

The NTSB's accident investigation identified the following safety issues:

  • Lack of small passenger vessel regulations requiring smoke detection in all accommodation spaces
  • Lack of roving patrol
  • Small passenger vessel construction regulations for means of escape
  • Ineffective company oversight

The NTSB determined that the probable cause of the accident on board the small passenger vessel Conception was the failure of Truth Aquatics, Inc., to provide effective oversight of its vessel and crewmember operations, including requirements to ensure that a roving patrol was maintained, which allowed a fire of unknown cause to grow, undetected, in the vicinity of the aft salon on the main deck. Contributing to the undetected growth of the fire was the lack of a United States Coast Guard regulatory requirement for smoke detection in all accommodation spaces. Contributing to the high loss of life were the inadequate emergency escape arrangements from the vessel's bunkroom, as both exited into a compartment that was engulfed in fire, thereby preventing escape.

Marine Accident Report 20/03 includes details of the NTSB's investigation and recommendations issued as a result of the investigation.

Collision between Liquefied Gas Carrier Genesis River and Voyager Tow

On May 10, 2019, the 754-foot-long liquefied gas carrier Genesis River collided with a 297-foot-long tank barge being pushed ahead by the 69-foot-long towing vessel Voyager on the Houston Ship Channel in Upper Galveston Bay. Immediately after the outbound Genesis River had passed an inbound liquefied gas carrier of similar size at the southern end of the Bayport Flare, it approached the channel's west bank, sheered to port, and crossed over to the opposite side of the channel where, in the barge lane ahead, the Voyager was pushing two tank barges breasted together side by side. In the ensuing collision, two cargo tanks in the starboard barge were breached, spilling over 11,000 barrels of petrochemical cargo into the waterway, and the port barge capsized. No injuries were reported.

The NTSB's accident investigation identified the following safety issues:

  • Challenges of navigating large vessels in the Bayport Flare area of the Houston Ship Channel
  • Vessel speed while transiting in a narrow channel

The NTSB determined that the probable cause of the collision between the liquefied gas carrier Genesis River and the Voyager tow was the Genesis River pilot's decision to transit at sea speed, out of maneuvering mode, which increased the hydrodynamic effects of the Bayport Flare's channel banks, reduced his ability to maintain control of the vessel after meeting another deep-draft vessel, and resulted in the Genesis River sheering across the channel toward the tow.

Marine Accident Report 21/01​ includes details of the NTSB's investigation and recommendations issued as a result of the investigation.