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Safety Recommendation Details

Safety Recommendation M-17-068
Details
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 TOTE SERVICES, INC.: Revise your safety management system and bridge resource management programs to contain detailed polices, instructions, procedures, and checklists to mitigate the risks of severe weather to your vessels.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Marine
Location: 36 NM Northeast Crooked Island Bahamas, AO, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: 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: TOTE Services, Inc. (Open - Acceptable Response)
Keyword(s):

Safety Recommendation History
From: TOTE Services, Inc.
To: NTSB
Date: 10/10/2019
Response: -From Jeff Dixon, President, TOTE Services, LLC: As stated in our May 7, 2018 letter, TOTE concurs with this recommendation. We have instituted various training measures to enhance the competency of our officers in Bridge Resource Management (“BRM”), over and above BRM training requirements set by law. As previously reported to you, we have implemented new procedures in our SMS, through OPSMEMO A-73, that provide for the convening of TOTE's Heavy Weather Advisory Team, with support provided by the Foss Maritime Center. Furthermore, to complement these changes and enhance BRM training, we have instituted through OPS-MEMO A-131 training on "Effective Assertion" concepts and techniques. We have previously described these initiatives to you, most recently in our letters dated May 7, 2018 and October 22, 2018. In addition, when we conduct our Heavy Weather Advisory Team calls, it is our practice to have a Meteorologist from our primary weather service provider brief on the call, as an additional resource for the Master and our shoreside team. In addition to these efforts, we have developed and implemented new heavy weather procedures and checklists, applicable to all TOTE-managed vessels. This is contained in Section 5.3.3 and checklist 36 of our Safety, Quality and Environment Management Manual. Under these new procedures, each vessel under our management is required to develop a ship-specific heavy weather checklist, to be used when any anticipation of heavy weather exists. Our TOTE-managed, government-owned vessels also adhere to their governing agency heavy weather plans on top of the requirements stated in our SMS. Additionally, all of our senior officers who currently work aboard vessels we manage have taken additional BRM training through the American Maritime Officers’ STAR Center. We have fully implemented and evaluated these new company BRM training requirements discussed above, and find them to be effective. Therefore, we believe Recommendation M-17-68 has been fully and appropriately addressed.

From: NTSB
To: TOTE Services, Inc.
Date: 3/11/2019
Response: We acknowledge that you disagree with our finding that you did not provide your vessels with a “heavy weather checklist.” You pointed out that TOTE’s existing SMS procedures require the International Chamber of Shipping Bridge Procedures Guide to be carried on board, and that it contains a heavy-weather checklist that may be used when anticipating heavy weather. We also understand that you disagree with our report with regard to BRM training for the El Faro’s crew. You point out that BRM training is part of the training protocols and requirements of the International Convention on Standards of Training, Certification and Watchkeeping for Seafarers, and is primarily accomplished through training programs established by maritime academies, license review programs, and the unions, not by vessel owners or operators. You also said that some, but not all, vessel operating companies provide supplemental BRM training on board their vessels, and that currently TOTE deck officers receive quarterly onboard BRM training under your SMS. You also disagree with our finding that the onboard BRM training was not performed on the El Faro at any time in the year before its sinking. We issued Safety Recommendation M-17-68 because El Faro’s crew did not use heavy weather checklists or procedures, nor did they seem to be aware of or discuss using such checklists or procedures. We also found evidence that junior officers were concerned about the proximity of the hurricane to the El Faro’s planned course, but these officers did not assertively express their concerns to the master, and the master did not act appropriately when the officers asked him to come to the bridge. We note that, despite your concerns, you have begun developing ship-specific heavy weather plans and checklists for vessels that you own, and you are recommending that owners of ships you manage also develop similar ship-specific heavy-weather plans and checklists. We further note that, to address BRM issues, you recently issued OPS-MEMO A-131, which introduced specific training on the concept of effective assertion. Under this new training initiative, masters and chief engineers conduct and document effective assertion training with all officers and unlicensed personnel as part of existing onboard BRM training. Finally, we note that you are continuing to evaluate the onboard, supplemental BRM training requirements, including the quality and effectiveness of existing training, and that during 2018, all of your senior officers took additional BRM training through the American Maritime Officers’ STAR Center. Pending completion of these actions, Safety Recommendation M-17-68 is classified OPEN--ACCEPTABLE RESPONSE.

From: TOTE Services, Inc.
To: NTSB
Date: 10/22/2018
Response: -From Philip H. Greene, Jr., President, TOTE Services, Inc.: As stated in our letter dated May 7, 2018, TOTE concurs with this recommendation. As previously reported to you, we have implemented new procedures in our SMS, through OPSMEMO A-73, that provide for the convening of TOTE's Hurricane Advisory Team, with support provided by the Foss Maritime Center. Furthermore, to complement these changes and enhance Bridge Resource Management training, we have instituted through OPS-MEMO A-131 training on "Effective Assertion" concepts and techniques. We have previously described these initiatives to you, most recently in our letter dated May 7, 2018. In addition to these efforts, we have developed and implemented new heavy weather procedures and checklists, applicable to all TOTE-managed vessels. This is contained in Section 5.3.3 and checklist 36 of our Safety, Quality and Environment Management Manual. Under these new procedures in our SMS, each vessel under management is required to develop a ship-specific heavy weather checklist, to be used when encountering heavy weather. All TOTE owned vessels have developed and implemented ship specific heavy weather checklists. Our government owned vessels under management adhere to their governing agency heavy weather plans, with our checklist provided as a backup specific to our SMS. We believe Recommendation M-17-68 has been fully and appropriately addressed.

From: TOTE Services, Inc.
To: NTSB
Date: 5/7/2018
Response: -From Philip H. Greene, Jr., President, TOTE Services, Inc. and Timothy Nolan, President, TOTE Maritime Puerto Rico: This letter acknowledges the e-mail of February 7, 2018, in which the Executive Secretariat, Office of the Managing Director, National Transportation Safety Board (“NTSB”) formally issued certain safety recommendations to TOTE Services, Inc. (“TOTE”). We have organized our responses below to correspond with the numbered safety recommendations to TOTE contained in the final report. Please note that all of the NTSB’s safety recommendations involve changes to vessel operations or capital improvements that exceed existing minimum standards set by law. Accordingly, as discussed further below, some recommendations, if adopted, may require capital improvements or other changes to vessels that are within the exclusive purview of the vessel owner, not the vessel operator. Accordingly, for vessels we manage that are not owned by one of our affiliated companies, we are contacting these external customers by letter to make them aware of these recommendations, so that they may consider these issues and initiate whatever changes they deem appropriate. Therefore, in many cases below, the response we provide only applies to the vessels that are owned by our affiliated companies. We try to make that distinction clear with respect to each recommendation. Additionally, please note that in our Supplemental Party Submission, submitted to the NTSB on January 11, 2018, we identified a number of factual errors that were stated on the record by certain staff at the NTSB’s Public Meeting. Our intent was for the public record to be clear, but many of the errors we raised were not corrected or otherwise addressed when the final NTSB report was published. In some cases below, we point out these errors, not to be argumentative, but to ensure implementation of the changes we are making to our safety procedures are put in their proper factual and operational context. TOTE Response: TOTE concurs with the intent of this recommendation. While we concur with the intent of the recommendation, we must reiterate at the outset that TOTE’s SMS provisions pertaining to heavy weather at the time of the accident voyage were in full compliance with the ISM Code and other applicable provisions of law, regulation, and policy. See TOTE Party Submission at pp. 49-53. We reiterated this in our Supplemental Party Submission. See TOTE’s Supplemental Party Submission, at pp 12-14. The NTSB’s final report does not refute this fact or cite evidence to the contrary. Instead, it appears the SMS heavy weather provisions were deemed deficient based on the so-called industry “benchmarking” survey. Our evidentiary objections to the flawed methodology of this survey are well documented and supported (see e.g. our letter dated August 22, 2017), but the issues we have raised, which call into question the legitimacy of this survey and the conclusions reached by relying on it, have never been addressed or refuted. We respectfully submit, for the reasons set forth in our prior submissions, that the benchmarking survey, as described by the Chairman of the Nautical Operations Group, lacks foundation and validity and did not (and currently does not) accurately reflect the status of industry norms, and therefore should not have been portrayed during the investigation as reflecting such industry standards. This brings us to a related point about safety culture, as stated by the Chairman of the Nautical Operations Group Chairman and Human Factors Group Chairman at the NTSB’s Public Meeting. The staff’s stated conclusion regarding safety culture was based on misstatements of fact, as described in our Supplemental Party submission, and described elsewhere in this submission. The conclusion also appears to be based on citing specific incidents where our procedures were deemed “inadequate.” As we pointed out in our prior submissions in great detail, but was not acknowledged or refuted in the final report, virtually every safety measure that the NTSB identified that TOTE did not have in place, or could have implemented differently, were not required by any law or regulation. There is no dispute that our procedures complied with applicable legal requirements, and countless provisions of our SMS indisputably exceed regulatory requirements and, with few minor exceptions, our personnel followed those procedures. This, alone, is indicative of a strong safety culture, not a weak one. And as we set out in great detail in our Supplemental Party Submission, but which again was not addressed or refuted in the final report, numerous witnesses – former employees, current employees, Coast Guard inspectors, and other independent third party witnesses – testified regarding TOTE’s healthy and positive safety culture. We respectfully disagree with any characterization of a weak safety culture at TOTE, and respectfully submit that any such overly broad conclusions are not a realistic or objective view of the entire evidence in the record. Regardless, as set forth herein, we have and will always be committed to continuously improving our safety performance. In regard to heavy weather procedures specifically, TOTE’s SMS, like any effective SMS, is continually evaluated for improvement in the interest of enhancing safety. In this regard, since the accident voyage, we have closely examined the heavy weather procedures contained in our SMS in light of what we have learned in the investigation. We have attempted to balance the master’s overriding authority to make navigational decisions while in supreme command of the vessel (as set forth in ISM Code Part A, section 5.2 and SOLAS Chapter V, Regulations 34 and 34-1) with our company’s unfailing commitment to safely operating our vessels as the top priority. Accordingly, and as an example, since the accident voyage, TOTE has established new procedures in its SMS, through OPS-MEMO A-73, that provide for the convening of TOTE’s Hurricane Advisory Team to affirmatively offer formal support and advice to vessel masters during cyclonic and other non-cyclonic weather events. Under these procedures now implemented in the SMS, we monitor at TOTE headquarters the real time position of all TOTE-managed vessels, and have access remotely to real time vessel positions. This is in addition to the assistance that is now available from the 24/7 manned information center (the Foss Maritime Center). The Foss Maritime Center was established in the summer of 2016. This Center assumed 24/7 emergency call responsibility for TOTE and Saltchuk-affiliated vessels. This initiative utilizes available joint resources and services among TOTE and Saltchuk sister companies. Although, as a matter of historical practice, 24/7 company reachback support was always available, and evidence in this case demonstrates that such advice and support was available to any master who requested it, OPS-MEMO A-73 and the implementation of TOTE’s Hurricane Advisory Team (and the Foss Maritime Center) now provides a formal mechanism for shoreside management to affirmatively offer that support. We believe this affirmative dialogue, though not required by the ISM Code or any regulation or industry standard we know of, appropriately further mitigates risk with regard to heavy weather at sea. With respect to Bridge Resource Management (“BRM”), it should be noted that BRM training is, first and foremost, part of the Coast Guard’s implementation and oversight of STCW training protocols and requirements, and is, as a practical matter, primarily accomplished through training programs, opportunities, and requirements established by maritime academies, license review programs, and the unions, not vessel owners or operators. This reality was seemingly lost in the final report. In our experience, some, but not all, vessel operating companies provide supplemental BRM training onboard the vessels. Currently with respect to BRM training at TOTE, TOTE deck officers receive: (a) required STCW BRM training supported and managed by the unions, and (b) quarterly onboard BRM training under TOTE’s SMS (this training goes beyond what is required by regulation). At the NTSB’s Public Meeting, the Chairman, Human Factors Group, incorrectly asserted that this onboard training was not performed onboard the EL FARO in 2015. The evidence showed that these training requirements were fully satisfied and current for those aboard the EL FARO. Our objections to this clear misstatement of facts were contained in our Supplemental Party Submission, along with citations to the evidence, yet the public record was not made clear in the NTSB’s subsequently issued final report. While we agree with the intent of the recommendation, the changes we are making to our BRM program must be viewed in the context of accurate facts, and in light of the existing role the unions and others play in delivering legally required BRM training. In addition, in regard to BRM, we recently issued OPSMEMO #A-131, which introduced specific training on the concept of “Effective Assertion”, and, to underscore its importance in our operations, was accompanied by a Safety Message from the President of TOTE Services. The purpose of this initiative is to reinforce the importance of communication that empowers “effective assertion” up, down, and across bridge and engineering teams in order to mitigate risk and disrupt an error chain, thus preventing an unsafe or dangerous event from occurring. “Effective assertion” is defined as the expression of one’s opinion or feelings clearly and confidently, with the purpose of highlighting an unsafe or potentially dangerous situation, with the goal of getting the attention of leadership (e.g., Master, Chief Engineer, Mate on Watch (“MOW”), Engineer on Watch (“EOW”), Maintenance/Deck Supervisor, etc.) so that risk mitigation steps can be taken to prevent an unsafe or dangerous situation from developing. Under this new training initiative, which we have implemented into our SMS, Masters and Chief Engineers will conduct and document training with all officers and unlicensed personnel on “Effective Assertion” principles, as part of existing onboard bridge/engineering resource management (“BRM/ERM”) training. Additionally, within 72 hours of a new crewmember reporting on board, Masters and Chief Engineers will conduct and document refresher BRM/ERM training with officers and unlicensed personnel that includes discussion on “Effective Assertion” principles. Because we agree with the intent of the recommendation, we are continuing to evaluate the onboard, supplemental BRM training requirements, including the quality and effectiveness of existing training methods, materials, and frequency. Additional BRM training is also available through the American Maritime Officers’ STAR Center. All Senior Officers assigned to vessels owned by TOTE-affiliated companies are currently scheduled to take this class in 2018, and we are recommending that our non-TOTE vessel owner clients support similar requirements for their vessels, where appropriate. This training goes yet another step beyond the minimum requirements, to include Navigation Watchkeeping Assessment training. In regard to heavy weather checklists, TOTE’s existing SMS procedures require the International Chamber of Shipping (“ICS”) Bridge Procedures Guide to be onboard, and that those procedures be followed for all TOTE-managed vessels. The ICS Guide contains a heavy weather checklist (Checklist B.10) that may be used when anticipating heavy weather. The Chairman, Nautical Operations Group misstated at the NTSB’s Public Meeting that there was “no evidence” the company provided its vessels a “heavy weather checklist,” and this fact “denoted a weak safety culture at the company.” In support of his position, he stated that seven of the nine companies who responded to the “benchmarking” survey provided such checklists to its vessels. As we pointed out in our letter of August 22, 2016, there was a heavy weather checklist onboard all of TOTE’s managed vessels, including the EL FARO, which is contained in the ICS Bridge Resource Guide, a publication required to be used onboard all TOTE-managed vessels under its SMS (see Checklist B.10 in the ICS Bridge Procedures Guide; see also OMV Section 10.1). The Chairman’s error made in the public record was not corrected in the NTSB’s final report. While we agree with the intent of the NTSB’s recommendation on this issue, we ask that the changes we have made and are making to our SMS be viewed in context of accurate facts. Because we agree with the intent of the recommendation, we have initiated development of ship specific heavy weather plans and/or checklists for vessels owned by TOTE-affiliated companies, and we are recommending to non-TOTE owners the development of similar ship-specific heavy weather plans and/or checklists. Any changes the owners wish to pursue will be implemented through appropriate changes to TOTE’ SMS, and vessel-specific SMS procedures, so that these changes can be institutionalized. We will keep you apprised of our progress in completing this effort.

From: NTSB
To: TOTE Services, Inc.
Date: 2/7/2018
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. 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 http://www.ntsb.gov. Among the safety recommendations are 10 issued to TOTE Services, Inc., which can be found on pages 253–254 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.