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Safety Recommendation Details

Safety Recommendation M-17-021
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 THE UNITED STATES COAST GUARD: Revise regulations to increase the minimum required propulsion and critical athwartships machinery angles of inclination. Concurrently, requirements for lifeboat launching angles should be increased above new machinery angles to provide a margin of safety for abandoning ship after machinery failure.
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 #: MAR-17-01
Accident Date: 10/1/2015
Issue Date: 2/7/2018
Date Closed: 4/30/2019
Addressee(s) and Addressee Status: USCG (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: USCG
Date: 4/30/2019
Response: Our investigation of El Faro’s sinking found that the port list caused by increasing wind on the vessel’s beam, coupled with the vessel’s motion, likely caused air to enter the bellmouth of the suction pipe to the lube oil service pump, which resulted in a loss of oil pressure that caused the main engine to shut down. One of the contributing factors we cited in the investigation report’s probable cause was loss of propulsion due to low lube oil pressure to the main engine, resulting from a sustained list. We issued Safety Recommendation M-17-21 based on our finding that increasing the minimum athwartships angle-of-inclination requirements for both static and dynamic conditions would provide an additional margin of safety for vessels exposed to high winds and large sea states. In addition, system safety principles require that lifeboats can be safely launched if the angles of inclination are exceeded because it is likely that, in such a scenario, the ship would have to be abandoned. We note that you do not concur with this recommendation, and you argue that current Safety of Life at Sea (SOLAS), classification society, and regulatory standards for minimum angles of inclination, which have been in place for many years, only require that certain static heel and trim conditions not interfere with the machinery’s operation. Because the actual performance of these systems is highly dependent on their particular design and configuration, the seakeeping characteristics of the vessel in which they are installed, and the crew’s routine and engineering casualty control procedures, you believe that these systems’ limitations can only be determined via operational experience. We further note that, to satisfy this recommendation, on April 3, 2018, you published a marine safety alert (MSA) informing maritime operators of your Marine Board of Investigation’s findings regarding the role that main propulsion lube oil sump level played in this accident. The MSA also recommended that operators verify compliance with minimum SOLAS, classification society, and regulatory standards, and ensure that their operating procedures address critical propulsion system limitations. Our El Faro investigation also found that the crew was most likely unaware of the main engine’s operational limitations from a sustained excessive list, and that if the ship’s officers had known the maximum static list angle at which the main propulsion engine would operate, they would most likely have attempted to reduce the initial list sooner, and possibly avoided the loss of propulsion. However, the MSA does not address the issue in Safety Recommendation M-17-21, which relates to ship design requirements and not to the crew’s knowledge and operational compliance with these standards. Regarding the lifeboat launching angles, you said that survival craft must be capable of launching at an unfavorable trim of 10 degrees and a list of 20 degrees. Because survival craft launching is an emergency procedure, you conclude that it is not appropriate to correlate it with the operational parameters of machinery systems. We disagree, and we believe that your conclusion is inconsistent with system safety principles. Being able to safely launch survival craft is a mitigation for a condition that places a vessel at risk. As the El Faro sinking shows, critical machinery shutdown due to excessive angles of inclination can result in such a catastrophic event. Without a requirement that survival craft can be safely launched after such an event, the mitigation will not effectively ensure safety. However, we note that you do not plan to take the recommended action, and you believe the recommendation should be closed. Therefore, Safety Recommendation M-17-21 is classified CLOSED--UNACCEPTABLE ACTION.

From: USCG
To: NTSB
Date: 7/17/2018
Response: -From Karl L. Schultz, Admiral, U.S. Coast Guard, Commandant: I do not concur with this recommendation. SOLAS, Classification Society, and regulatory standards for minimum angles of inclination at which machinery must be designed to operate have been in place for many years. These standards only require that certain static heel and trim conditions not interfere with the machinery's operation. The actual performance of such engineering systems is highly dependent on their particular design and configuration, the seakeeping characteristics of the vessel in which they are installed, and the crew's routine and engineering casualty control procedures. Only through operational experience can the limitations of these systems be determined. To reduce the potential for similar casualties, the Coast Guard published a Marine Safety Alert on April 3, 2018, that informed maritime operators of the Coast Guard's Marine Board of Investigation findings regarding the role that main propulsion lube oil sump level may have played in this casualty. The Alert recommends that operators verify compliance with minimum SOLAS, Classification Society, and regulatory standards, and ensure that their operating procedures address critical propulsion system limitations and actions that should be taken to mitigate the consequences when those limitations are exceeded. Survival craft must be capable of launching at unfavorable trim and list of 10° and 20°, respectively. As the launching of survival craft is an emergency procedure, it is not appropriate to correlate it to the operational parameters of machinery systems. I consider the Coast Guard's action on this recommendation complete and request that it be closed.

From: NTSB
To: USCG
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 http://www.ntsb.gov. 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 correspondence@ntsb.gov. 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.