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Safety Recommendation Details

Safety Recommendation M-17-011
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: Modify your directives to ensure, for all tropical cyclones of tropical storm strength or greater within your jurisdiction, that your facilities issue, at the 3-hour interval between regularly scheduled Tropical Cyclone Forecast/Advisories, an Intermediate Public Advisory, a Tropical Cyclone Update, or another product available (or expected to be available) to mariners via Inmarsat-C SafetyNET (and appropriate future technology), and that the product include coordinates of current storm center position, maximum sustained surface winds, current movement, and minimum central pressure.
Original recommendation transmittal letter: PDF
Overall Status: Open - Await 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 - Await 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: We understand that this recommendation, as issued, would not provide mariners with additional information on named storms at the 3-hour interval between regularly scheduled 6 hour advisories. On May 24, 2018, our staff met with NWS staff to discuss this and other recommendations from the El Faro investigation. Based on conversations during that meeting, we were hopeful that an alternative solution could be developed to distribute new storm information to mariners even when coastal watches or warnings are not in effect. We believe the best way forward would be for our staff and NWS staff to meet and further discuss this issue and possible alternative ways to satisfy this recommendation. We will contact the NWS to schedule this meeting. Pending the results of that discussion, Safety Recommendation M-17-11 remains classified OPEN--AWAIT 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: In addition to resource infeasibility (e.g. personnel, reconnaissance flights) noted in NWS response to M-17-10, the NWS is concerned that this recommendation is not based on correct information and may not benefit mariners as NTSB intended. When tropical storm or hurricane watches/warnings are in effect on land, NHC issues an "intermediate" advisory (IA) or equivalent product midway (i.e., after 3 hours) between its 6-hourly forecast products. IAs provide estimated current storm location, intensity, and motion. IAs do not update the forecast. They are provided for situational awareness for customers on land, taking advantage of (and serving) the media's continuous news programming during landfall periods. The utility of IAs for decision making by the marine customer is even more limited, since not only do IAs not contain new forecast information, but their hazard and warning information is for land areas only. When coastal watches/warnings are in effect, the IA is informed more than half of the time by reconnaissance aircraft data, and/or land or near-shore surface observations, or radar data. These data usually make it possible to provide a reliable 3-hourly estimate of storm characteristics. The NTSB might also not be aware that when satellites are the primary source of information, as is the case the majority of the time (i.e., when no reconnaissance aircraft data are available), the uncertainty about a storm's analyzed location averages around 20-30 nm and the intensity uncertainty averages around 5-15 knots. NHC's average 3-hour track and intensity forecast errors, however, (interpolated from 0 and 12 hour error data) are near 13 nm and 3 knots, respectively. The result is that without aircraft data, the noise is almost always much larger than the signal at the times IAs are issued. However, on the rare occasion when "fix" data for a non-watch/warning storm are available, and those data indicate the storm has changed in an unexpected and significant way from the existing forecast, the NHC does issue Special Advisory products. Those products include not only the updated current storm information, but a full new forecast accounting for the change. The NHC issued 19 such Special Advisory product "packages" for its Atlantic area of responsibility from 2014-2017. Note that NHC is working to specify quantitative guidelines for the issuance of Special Advisories in response to recommendation M-17-13. This change will ensure that marine customers will know the thresholds at which Special Advisories will be issued when significant changes have occurred related to the storm's initial characteristics or forecast. Adopting recommendation M-17-11 would increase the number of NHC IAs (or a similar product) issued by 250%. with only 5% of those additional products based on, and providing users with, new information. From 2014-17. the NHC issued an average of 166 IAs per season in its Atlantic and eastern North Pacific areas of responsibility for tropical storms and hurricanes when watches/warnings were in effect. Providing an IA during every 6-hour period instead would have required an average of 403 IAs per season--about two and a half times as many of these products, none of which would have indicated a significant change (i.e., would have warranted a Special Advisory). The NWS believes the user community would be better served by not taking time away from the forecaster's existing duties, in an already tight schedule and complex workflow. to generate products that do not improve upon existing information.

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 disagree with this recommendation, believing it is not based on correct information and that it may not benefit mariners. We further note that you think it is unfeasible with respect to available resources and logistics because when coastal watches or warnings are in effect, more than half of the time intermediate advisories (IAs), such as an intermediate public advisory or a tropical cyclone update, are based on reconnaissance aircraft data, land or near-shore surface observations, or radar data, but when coastal watches or warnings are not in effect, such information is available only 5 percent of the time because reconnaissance aircraft only observe storms that are near-term threats to land. Such storms are also too distant from land for land-based radar or surface observation networks to provide data that can be used to reliably estimate the storm’s location, motion, or intensity every 3 hours. When satellites are the primary source of information, such as when no reconnaissance aircraft data are available, the uncertainty about a storm’s analyzed location averages around 20 to 30 nautical miles (nm), and the intensity uncertainty averages around 5 to 15 knots (kt). In comparison, the National Hurricane Center’s (NHC’s) average 3-hour track and intensity forecast errors are near 13 nm and 3 kt, respectively. As a result, you believe that without aircraft data, noise in the information used to determine a storm’s center position, maximum sustained surface winds, current movement, and minimum central pressure are almost always much larger than the signal at the times IAs are issued. According to Mr. Stern’s letter, adding IAs would greatly increase forecasters’ workloads. Providing an IA every 6 hours during 2014 to 2017 would have required about two and a half times as many of these products, none of which would have indicated a significant change. As a result, you believe the user community would be better served by not taking time away from the forecaster’s existing duties to generate products that do not improve upon existing information. We acknowledge this argument; however, we continue to believe it is important to distribute new information about a storm to mariners even when coastal watches or warnings are not in effect. We believe that when we meet with your staff regarding the El Faro investigation, we will be able to discuss the issue in this recommendation and possible alternatives that you may be able to pursue. Pending that meeting and the results of that discussion, Safety Recommendation M-17-11 remains classified OPEN--AWAIT 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 is concerned that this recommendation is not based on correct information and may not benefit mariners as NTSB intended, in addition to being unfeasible with respect to available resources and logistics (e.g. personnel, reconnaissance flights) at this time. When tropical storm or hurricane watches/warnings are in effect on land, NHC issues an "intermediate" advisory or equivalent product (IA) midway (i.e., after 3 hours) between its 6-hourly forecast products. IAs provide estimated current storm location, intensity, and motion. IAs are provided for situational awareness for customers on /and-they do not update the forecast or information on hazards or preparedness activities. Their utility for decision making for the marine customer is even more limited, since IAs do not contain new forecast information and only contain land-based hazard and warning information. When coastal watches/warnings are in effect, the IA is informed more than half of the time by reconnaissance aircraft data, and/or land or near-shore surface observations, or radar data. These data usually make it possible to provide a reliable 3-hourly estimate of storm characteristics. The NTSB might not have been aware that, on the other hand, when coastal watches/warning are not in effect, such ufix" information is available only around 5% of the time. This percentage is not higher mainly because reconnaissance aircraft, which operate at considerable expense, are tasked only to observe storms that are near-term threats to land. Such storms are also too distant from land for land-based radar or surface observation networks to provide data that can be used to make a reliable 3-hourly estimate of the storm location, motion, or intensity. Microwave satellite imagery contribute to short-term updates only on an infrequent basis due to intermittent coverage. Also, the next formal Dvorak satellite analysis after the 6-hourly advisory is not available to the forecasters until more than three hours later, after the deadline for issuing an IA. The NTSB might also not be aware that when satellites are the primary source of information, as is the case the majority of the time (i.e., when no reconnaissance aircraft data available), the uncertainty about a storm's analyzed location averages around 20-30 nm and the intensity uncertainty averages around 5-15 kt. NHC's average 3-hour track and intensity forecast errors, however, (interpolated from 0 and 12 hour error data) are near 13 nm and 3 kt, respectively. The result is that without aircraft data, the noise is almost always much larger than the signal at the times IAs are issued. However, on the rare occasion when "fix" data for a non-watch/warning storm are available, and those data indicate the storm has changed in an unexpected and significant way from the existing forecast, the NHC issues Special Advisory products. Those products include not only the updated current storm information, but a full new forecast accounting for the change. The NHC issued 19 such Special Advisory product "packages" for its Atlantic area of responsibility from 2014-2017. Adding IAs would result in a very large increase in forecaster workload. From 2014-17, the NHC issued an average of 166 IAs per season in its Atlantic and eastern North Pacific areas of responsibility for tropical storms and hurricanes when watches/warnings were in effect. Providing an IA during every 6-hour period instead would have required an average of 403 IAs per season-about two and a half times as many of these products, none of which would have indicated a significant change (i.e., would have warranted a Special Advisory). The NWS believes the user community would be better served by not taking time away from the forecaster's existing duties, in an already tight schedule and complex workflow, to generate products that do not improve upon existing information.

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.