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Safety Recommendation Details

Safety Recommendation M-17-015
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: Allow users to schedule recurring, automated receipt of specific National Weather Service products through an enhanced FTPmail service (and appropriate future technology).
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
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: 4/22/2019
Addressee(s) and Addressee Status: United States Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: United States Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service
To: NTSB
Date: 7/14/2019
Response: -From John D. Murphy, Chief Operating Officer, NOAA National Weather Service: Per discussion with the NTSB in May 2018, NWS understands the reasoning behind this recommendation, but does not currently have resources to enable transitioning FTPmail to a service that would allow recurring, automated product delivery. As future iterations of and updates to FTPmail or alternatives to FTPmail are explored, this recommendation will be revisited. However, for the immediate future, NWS agrees with the NTSB’s “closed” designation for this recommendation.

From: NTSB
To: United States Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service
Date: 4/22/2019
Response: We recognize that implementing and maintaining a new type of software for the FTPmail service would involve significant cost and effort; however, we continue to believe that the FTPmail service is an important source of weather information for vessels on which crewmembers can send and receive e-mail. As discussed in our El Faro report, NWS products that relay important information about tropical cyclones are not available via well-established means, such as Inmarsat¬ C SafetyNET, NAVTEX, and Coast Guard HF radio. Further, even if a product is available, its broadcast or availability may be delayed. FTPmail service may be the most efficient means by which to supplement those products on vessels whose crews have access to e-mail but not to the open Internet. However, because the NWS has made it clear that it does not intend to make this improvement, Safety Recommendation M-17-15 is classified CLOSED--UNACCEPTABLE ACTION.

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: NWS does not plan to pursue this recommendation, per discussion with NTSB. For the NTSB's consideration, the practices recommended here cannot be achieved through enhancement of the current software and would require a new type of software for the ftpmail service. The current software used for FTPmail is a freeware and does not support a user to set up recurring/automated receipt of products. A new FTP service would have to be purchased and implemented to satisfy this recommendation. Funding or resources to run and manage this type of upgrade in service has not currently been identified. The NWS also questions whether this type of service is the role of the Federal Government. There are several private companies that offer subscription services. It is NWS' position that this action not be pursued at this time.

From: NTSB
To: United States Department of Commerce, National Oceanic and Atmospheric Administration, National Weather Service
Date: 2/20/2018
Response: We understand that satisfying this recommendation may involve significant costs and effort. We also believe there will be a considerable safety benefit if the recommended revision is made. We look forward to a detailed discussion of this recommendation and the associated FTPmail service software revisions necessary when we meet to discuss the findings of our investigation of the El Faro sinking. Based on the results of that discussion, we will determine if there are feasible approaches to satisfying this recommendation and implementing the associated safety improvement. Pending the results of the meeting and our determination of the feasibility of accomplishing the recommended improvements, Safety Recommendation M-17-15 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: For the NTSB's consideration, the practices recommended here cannot be achieved through enhancement of the current software and would require a new type of software for the ftpmail service. The FTPMail software does not offer the features the report recommends. NAVTEX is a medium frequency (518 kHz), direct-printing service for the delivery of navigational and meteorological warnings and is part of the Global Marine Distress Safety System. The nine NAVTEX forecasts prepared by the NWS are designed to accommodate the listening area of the nine respective transmitters. Even though the required listening area is only within 200 nm of the sea buoy near the transmitter, most NWS NAVTEX products are extended for continuous cover of all waters within 200 nm of the CON US coastline. Thus, NAVTEX is not a suitable service for dissemination of tropical cyclone information beyond 200 nm in the Offshore Waters Forecast (OFF) domain, and most of the High Seas Forecast (HSF) domain. NAVTEX messages are restricted to less than 89 lines, and messages exceeding that amount are often truncated. Additionally, meteorological messages are lower priority than navigational safety messages, ice reports, search and rescue information and piracy alerts. Thus, NAVTEX is not a guaranteed dissemination service for all tropical cyclone information. HF Voice: The U.S. Coast Guard (USCG) should be contacted as for the feasibility of using the "Iron Mike" synthesized voice system to disseminate the tropical cyclone Forecast Advisory (TCM). However, this change could be considered an unnecessary duplication of the tropical cyclone information contained within the HSFs and OFFs which are already disseminated via HF Voice. HF SITOR: The USCG currently broadcasts the HSFs from four communication stations in the SITOR mode. Tropical cyclone information is contained within the HSF. Additionally, the HSF provides a forecast of the radius of 12-foot seas beyond the initial conditions contained within the TCM product. Forecasts are also provided for sub-tropical-storm-force winds of 20-33 knots and seas of 8 to 12 feet surrounding the forecasted tropical storm force wind (34-knot radii) and 12-foot radii. Additionally, the transmission range of the SJTOR broadcast is dependent upon operating frequency, time of day, and atmospheric conditions - and can vary from only short distances to several thousand miles. An additional consideration is the inclusion in the recommendation of the dissemination of forecast graphics that are produced by the Department of Defense (DOD). These may not be cleared for public distribution.

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.