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Safety Recommendation Details

Safety Recommendation M-17-010
Details
Synopsis: The National Transportation Safety Board (NTSB) is providing the following information to urge the National Oceanic and Atmospheric Administration (NOAA), the National Weather Service (NWS; a component of NOAA), and the US Coast Guard to take action on the safety recommendations in this report. The recommendations address, in the interest of mariner safety, the development of tropical cyclone information and its availability to mariners. The recommendations derive primarily from factual information gathered during the NTSB’s ongoing investigation into the sinking of cargo vessel El Faro on October 1, 2015. The factual data revealed that critical tropical cyclone information issued by the NWS is not always available to mariners via well-established broadcast methods. The data also suggest that modifying the way the NWS develops certain tropical cyclone forecasts and advisories could help mariners at sea better understand and respond to tropical cyclones. Further, factual data on the official forecasts for Hurricane Joaquin and other recent tropical cyclones suggest that a new emphasis on improving hurricane forecasts is warranted. The NTSB has yet to determine the probable cause of, or contributing factors in, El Faro’s sinking. Nevertheless, based on the meteorological facts gathered thus far, plus discussions with the NWS and the Coast Guard, the NTSB makes ten recommendations in this report. Two recommendations are addressed to NOAA, seven to the NWS, and one to the Coast Guard.
Recommendation: TO THE NATIONAL WEATHER SERVICE: Work with international partners to develop and implement a plan to ensure immediate dissemination to mariners, via Inmarsat-C SafetyNET (and appropriate future technology), of the Intermediate Public Advisories and Tropical Cyclone Updates issued by the National Weather Service, in a manner similar to the current process of disseminating the Tropical Cyclone Forecast/Advisory.
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
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 #: MSR-17-02
Accident Date: 10/1/2015
Issue Date: 6/29/2017
Date Closed:
Addressee(s) and Addressee Status: United States Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service (Open - Unacceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: United States Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service
Date: 4/22/2019
Response: The NWS indicated that, although it is technically possible to add intermediate public advisories and tropical cyclone updates to the current SafetyNET broadcast cycle, it does not recommend doing so because of the current high volume of worldwide products disseminated by that system; as a result, routine messaging can overwhelm mariners because they cannot control the type and number of products they receive, including many intended for users far outside their areas of operation. The NWS indicated that the additional transmission load of intermediate public advisories and tropical cyclone updates would likely compound this problem. We agree that these concerns should be addressed; however, we do not believe that the solution is to deny mariners critical, up-to-date information regarding a tropical cyclone’s position, intensity, and movement. We are hopeful that the future version of SafetyNET will solve some of the problems that the NWS highlighted, and we urge the NWS not to delay its implementation. In the meantime, because we remain concerned that intermediate public advisories and tropical cyclone updates will not be included as part of the current SafetyNET broadcast to mariners, Safety Recommendation M 17 10 is classified OPEN--UNACCEPTABLE RESPONSE.

From: United States Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service
To: NTSB
Date: 7/15/2018
Response: -From Andrew Stern, Director, Analyze, Forecast, and Support Office, NOAA/ National Weather Service: I would like to bring to your attention increased support that NWS is providing to the U.S. Coast Guard with respect to improving dissemination of hazards in the oceanic domain. Starting last week, the NWS Ocean Prediction Center, in coordination with the National Hurricane Center and the NWS National Operations Center began providing weekly PPT briefings to USCG District 5. Note in the attached Memo from OPC to the NWS Chief Operating Officer that the actions fully support safety recommendations from the NTSB El Faro report. The second attached file, called "Briefing Slides.pdf", contains briefing slides from last week. The first two slides were presented to the USCG on July 9 and highlighted hazards associated with cyclones Chris and Beryl. The 3rd and 4th slides show updates to NWS leadership regarding oceanic impacts from Hurricane Chris. Slide 3 shows AIS data and ship avoidance maneuvers in advance of Chris - leaving a mostly ship free northeastward slot. Slide 4 shows a tanker who appeared to move close to or through the eye wall. OPC later reported that the tanker turned northwest and headed toward the NY Bight once the storm had passed. The NWS continues to improve decision support services with our core partners in support of transportation safety. Thought that you would be interested.

From: United States Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service
To: NTSB
Date: 6/22/2018
Response: -From Andrew D. Stern, Director, National Weather Service, Analyze, Forecast and Support Office: While it is technically possible to add intermediate public advisories and tropical cyclone updates to the current SafetyNet broadcast cycle, it is not recommended by NWS, as the overall utility to customers could be degraded. • Potential Problem (external)- Routine broadcasts over SafetyNet can overwhelm mariners (SafetyNet users cannot completely control what they receive), and adding more products could make the broadcast cycle too long (some products are broadcast several times). • Potential Problem (external)- lnmarsat C satellites cover large areas, and some broadcasts do not apply to all portions of an area. This problem occurred the night of the El Faro accident, as described in NTSB/MSR-17/02 on page 9 ... [Third Mate 22:38:09.8 "(the weather/hello); Third Mate 22:38:15.1 "(I don't know) it's for the Pacific unfortunately"]. Many users would be receiving tropical cyclone products not intended for their area. • Potential Problem (internal) - This recommendation would significantly increase the amount of updates required for the High Seas Forecast for MetAreas IV and XII during tropical cyclone events. It would create workload and staffing problems at the NWS Ocean Prediction Center (OPC), NWS National Hurricane Center's (NHC) Tropical Analysis and Forecast Branch, and the NWS Honolulu Forecast Office (all produce High Seas Forecasts for IV and XII). See further workload explanation in NWS Input for M-17-11. Some of these issues may be remediated with the implementation of SafetyNet 11, but the timing of the implementation and full capabilities are unknown. Per the justification in Recommendation M-17-11 and the NWS conversation with the NTSB on May 24th, the NWS does not plan to send out routine Intermediate Public Advisories, but will continue to send out Special Advisories per guidance proposed on response to Recommendation M-17-13.

From: NTSB
To: United States Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service
Date: 2/20/2018
Response: We note that you do not believe Inmarsat-C would be effective for disseminating intermediate public advisories and tropical cyclone updates because of the current high volume of worldwide products disseminated by that system; as a result, routine messaging can overwhelm mariners because they cannot control the type and number of products they receive, including many intended for users far outside their areas of operation. You believe the additional transmission load of intermediate public advisories and tropical cyclone updates would likely compound this problem. As an alternative, you suggest employing the SafetyNET features of geographic alerting polygons, which would permit more focused transmission to intended audiences while not overburdening those ships well outside of the potentially affected areas. Although we acknowledge that the volume of information transmitted through Inmarsat C can be a problem, it remains the most appropriate global means to transmit important weather information to mariners. Because Inmarsat-C is required equipment that must be monitored, it is highly likely that important weather information will be received by ships at sea who need it. Our investigation showed that the El Faro received its best and most timely weather information from Inmarsat-C, which gave the vessel the best chance to mitigate the storm. We encourage your efforts to better target weather information to the relevant mariners; however, the safety need for this information is so great that we disagree with you waiting to make the recommended change until after geographic alerting polygons or other techniques are developed and implemented that address the volume of information. Pending your completing the recommended action, Safety Recommendation M 17 10 is classified OPEN—ACCEPTABLE RESPONSE.

From: United States Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service
To: NTSB
Date: 11/30/2017
Response: -From Andrew D. Stern, Director, Analyze, Forecast, and Support Office, National Weather Service: The NWS does not believe lnmarsat-C would be effective as a means to enable provision of Intermediate Advisories. The current high volume of worldwide products disseminated by that system for even routine messaging can overwhelm mariners because they do not control the type and number of products they receive, including many intended for users far outside their area of operation. This problem occurred the night of the accident, as described in NTSB/MSR-17/02 on page 9 ... [Third Mate 22:38:09.8 "(the weather/hello); Third Mate 22:38:15.1 "(I don't know) it's for the Pacific unfortunately"]. The additional transmission load of Intermediate Advisories would likely compound this problem, rather than alleviate it. One possible option NTSB might explore for addressing Jnmarsat-C dissemination would be to recommend employing "Safety Net" features of geographic alerting polygons. This would allow for the provision of more focused transmission to intended audiences, while not overburdening those ships well outside of the potentially affected areas. This should also alleviate much of the congestion concerns on the system. At a minimum, the NWS suggests that this recommendation be vetted by the user community due to the potential negative impacts.

From: NTSB
To: United States Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service
Date: 6/29/2017
Response: On June 20, 2017, the National Transportation Safety Board (NTSB) adopted its safety recommendation report Tropical Cyclone Information for Mariners, related to the October 1, 2015, sinking of cargo vessel El Faro. Additional information about this accident and the resulting recommendations may be found in the safety recommendation report, which can be accessed at our website, www.ntsb.gov, under report number NTSB/MSR-17/02. As a result of this investigation, we issued two recommendations to the National Oceanic and Atmospheric Administration, one recommendation to the US Coast Guard, and the following seven recommendations to the National Weather Service.