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Safety Recommendation Details

Safety Recommendation M-17-023
Synopsis: 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. As part of its accident investigation, the National Transportation Safety Board (NTSB) led a joint effort with the US Navy, Woods Hole Oceanographic Institution, and the National Science Foundation to locate the ship’s wreckage and retrieve its voyage data recorder (VDR). The VDR was pulled from 15,250 feet below the ocean surface in August 2016 during the third undersea mission and yielded more than 26 hours of parametric data and audio files. 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 cargo holds, loss of propulsion, downflooding through ventilation closures, need for damage control plan, and lack of appropriate survival craft. The NTSB made safety recommendations to the US Coast Guard; the Federal Communications Commission; the National Oceanic and Atmospheric Administration; the International Association of Classification Societies; the American Bureau of Shipping; Furuno Electric Company, Ltd.; and TOTE Services, Inc.
Recommendation: TO THE UNITED STATES COAST GUARD: Propose to the International Maritime Organization 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.
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable Response
Mode: Marine
Location: 36 NM Northeast Crooked Island Bahamas, AO, United States
Is Reiterated: No
Is Hazmat: No
Accident #: DCA16MM001
Accident Reports: Tropical Cyclone Information for Mariners Sinking of US Cargo Vessel SS El Faro Atlantic Ocean, Northeast of Acklins and Crooked Island, BahamasSinking of the US Cargo Vessel El Faro: Illustrated Digest
Report #: MAR-17-01
Accident Date: 10/1/2015
Issue Date: 2/7/2018
Date Closed:
Addressee(s) and Addressee Status: USCG (Open - Unacceptable Response)

Safety Recommendation History
From: NTSB
Date: 4/30/2019
Response: We note that, since 1992, SOLAS has required cargo ship stability information to include precautions necessary to maintain adequate ship stability. We further note that watertight access doors, hatch covers, and external openings on all cargo ships constructed after 1992 are currently required to be fitted with open/closed indicators on the bridge; however, cargo ships built before 1992 are not subject to these requirements. Because you believe that the most expeditious means to address these recommendations for ships constructed before 1992 is to include appropriate information in the ship’s safety management system (SMS), you plan to satisfy these recommendations by revising your supplemental flag state guidance regarding SMS development and implementation. You believe that your recently promulgated supplemental flag state guidance regarding SMS development and implementation, “USCG Oversight of Safety Management Systems on U.S. Flag Vessels,” issued March 23, 2018, fully addresses these matters. We disagree that the revisions to your SMS guidance fully satisfy Safety Recommendations M 17 22 and -23, which specifically recommend that you make proposals to the IMO. The revisions to your supplemental flag state guidance regarding SMS development and implementation do not satisfy these recommendations because they will only apply to your domestic inspection program for domestic US-flagged vessels, ignoring the majority of international shipping that does not involve US-flagged vessels. Pending your making the recommended proposals to the IMO, Safety Recommendations M-17-22 and -23 are classified OPEN--UNACCEPTABLE RESPONSE.

From: USCG
Date: 7/17/2018
Response: -From Karl L. Schultz, Admiral, U.S. Coast Guard, Commandant: I concur with the intent of this recommendation. All cargo ships constructed after 1992 are required to meet damage stability criterion that require most watertight access doors, hatch covers and external openings to be fitted with open/closed indicators on the bridge (see SOLAS 90 regulations 11-1/25-9and11-1/25-10 and SOLAS 2009 regulations II-1/13-1 and II-1115-1). However, cargo ships built before 1992 are not required to meet damage stability criterion and therefore lack regulatory established watertight boundaries. Thus, there are no regulatory required "watertight" closures to fit indicators. Notwithstanding the absence of damage stability regulations prior to 1992, the concept of watertight integrity has always been fundamental from a ship design and operational standpoint. The Coast Guard has addressed this matter in the recently promulgated supplemental flag State guidance regarding the development and implementation of SMSs. I consider the Coast Guard's action on this matter complete and request that it be closed.

From: NTSB
Date: 2/7/2018
Response: On December 12, 2017, the NTSB adopted its report Sinking of US Cargo Vessel SS El Faro, Atlantic Ocean, Northeast of Acklins and Crooked Island, Bahamas, October 1, 2015, NTSB/MAR-17/01. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at Among the safety recommendations are 29 issued to the US Coast Guard, which can be found on pages 248–251 of the report. The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number. We encourage you to submit your response to If it exceeds 20 megabytes, including attachments, please e-mail us at the same address for instructions. Please do not submit both an electronic copy and a hard copy of the same response.