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 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 sinking, 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 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.

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 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 casualty 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. 

​​Capsizing and Sinking of Commercial Fishing Vessel Scandies Rose

On December 31, 2019, about 2200 Alaska standard time, US Coast Guard Communications Detachment Kodiak received a distress call from the commercial fishing vessel Scandies Rose. The vessel was en route from Kodiak to fishing grounds in the Bering Sea when it capsized about 2.5 miles south of Sutwik Island, Alaska, and sank several minutes later. At the time of the casualty, the Scandies Rose had seven crewmembers aboard, two of whom were rescued by the Coast Guard several hours later. The other missing crewmembers were not found and are presumed dead. The Scandies Rose, valued at $15 million, was declared a total loss.

The NTSB's investigation identified the following safety issues:

  • The effect of extreme icing conditions
  • The vessel’s inaccurate stability instructions
  • Need to update regulatory guidelines on calculating and communicating icing for vessel stability instructions
  • Lack of accurate weather data for the casualty area

The NTSB determined that the probable cause of the capsizing and sinking of the commercial fishing vessel Scandies Rose was the inaccurate stability instructions for the vessel, which resulted in a low margin of stability to resist capsizing, combined with the heavy asymmetric ice accumulation on the vessel due to localized wind and sea conditions that were more extreme than forecasted during the casualty voyage.

Marine Accident Report 21/02 includes details of the NTSB's investigation and recommendations issued as a result of the investigation.

Capsizing of Roll-on/Roll-off Vehicle Carrier Golden Ray

On September 8, 2019, while navigating outbound from the Port of Brunswick, Georgia, through the Brunswick River and into the St. Simons Sound, the pilot aboard the roll-on/roll-off vehicle carrier Golden Ray gave rudder orders to turn the vessel to starboard, and the vessel began to heel quickly to port. Despite the bridge crew’s attempts to counter the heeling, the vessel continued to heel over, eventually settling on its port side at an angle of 90°. Responders were initially able to rescue the pilot and 19 of the 23 crewmembers on board. Four engineering crewmembers remained trapped in the engine room until the following day, when responders cut into the vessel’s hull to rescue them. Two crewmembers suffered serious injuries. Total costs for the loss of the vessel were estimated at $62.5 million, and total costs for the loss of the cargo were estimated at $142 million. 

The NTSB's investigation identified the following safety issues:

  • Improperly calculating vessel stability
  • Lack of company oversight for calculating vessel stability

The National Transportation Safety Board determines that the probable cause of the capsizing of the Golden Ray was the chief officer’s error entering ballast quantities into the stability calculation program, which led to his incorrect determination of the vessel’s stability and resulted in the Golden Ray having an insufficient righting arm to counteract the forces developed during a turn while transiting outbound from the Port of Brunswick through St. Simons Sound. Contributing to the casualty was G-Marine Service Co. Ltd.’s lack of effective procedures in their safety management system for verifying stability calculations.

Marine Accident Report 21/03 includes details of the NTSB's investigation and recommendations issued as a result of the investigation.

Hazardous Liquid Pipeline Strike and Subsequent Explosion and Fire aboard Dredging Vessel Waymon Boyd

On August 21, 2020, about 0802 central daylight time, the US-flagged dredge Waymon Boyd struck a submerged 16-inch liquid propane pipeline during dredging operations in Corpus Christi, Texas. A geyser of propane gas and water erupted adjacent to the vessel. Shortly thereafter, propane gas engulfed the vessel, and an explosion occurred. Fire damaged the vessel and surrounding shoreline. A total of 18 personnel employed by Orion Marine Group were working or resting on the dredge and assist boats (tender boats, anchor barges, booster barges, and a supply barge) on the day of the casualty. Three crewmembers aboard the Waymon Boyd and one on an adjacent anchor barge died in the explosion and fire. Six crewmembers aboard the dredge were injured, one of whom later died from his injuries. The Waymon Boyd, valued at $9.48 million, was a total loss. The cost of pipeline damage was $2.09 million. The cost of physical damage to the EPIC facility was $120,000. 

The NTSB's investigation identified the following safety issues:

  • Inadequate project planning and risk assessment
  • Ineffective pipeline damage prevention
  • Lack of pipeline hazard training

The NTSB determined that the probable cause of the hazardous liquid pipeline breach, propane release, and subsequent explosion and fire aboard the dredging vessel Waymon Boyd was Orion Marine Group’s inadequate planning and risk management processes, which failed to identify the proximity of their dredging operation to Enterprise Products’ pipeline TX219 and resulted in the absence of effective controls to prevent the dredge’s cutterhead from striking the pipeline. Contributing to the casualty were deficient dredging plans provided by Schneider Engineering and Consulting, which resulted in incomplete and inaccurate information communicated to Enterprise Products by Orion Marine Group during the one-call process, which resulted in insufficient measures to protect the pipeline from excavation damage.

Marine Accident Report 21/05 includes details of the NTSB's investigation and recommendations issued as a result of the investigation. ​


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