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Safety Recommendation Details

Safety Recommendation M-17-028
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: Require that information regarding openings that could lead to downflooding be included in damage control documents, stability instruments and booklets, and safety management systems for vessels subject to the intact stability criteria of Title 46 Code of Federal Regulations 170.170, regardless of the designation or treatment of such openings in intact stability calculations.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Acceptable Alternate 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 - Acceptable Alternate Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: USCG
Date: 4/30/2019
Response: We note that you agree that information regarding openings that could lead to downflooding should be available to a vessel’s master. US vessels subject to 46 CFR 170.170 and SOLAS and constructed after 1992 are currently required to have comprehensive damage-control information on board. These vessels are also required to have similar information in their stability booklets in accordance with 46 CFR 170.110, including guidance for safely operating the vessel under normal and emergency conditions. Therefore, you believe that this recommendation was already satisfied for US vessels built since 1992 that are subject to SOLAS. However, as you said in your letter, the IMO decided not to apply these standards retroactively. We note that, with respect to vessels constructed before 1992, you have included guidance in “USCG Oversight of Safety Management Systems on U.S. Flag Vessels” that a vessel’s SMS must include appropriate operational procedures to address the issue discussed in Safety Recommendation M-17-28. We agree that vessels constructed after 1992 are already subject to the requirements in this recommendation. The revisions to your guidance on a vessel’s SMS are an acceptable alternative to the recommended requirement in Safety Recommendation M-17-28, which is classified CLOSED--ACCEPTABLE ALTERNATE ACTION.

From: USCG
To: NTSB
Date: 7/17/2018
Response: -From Karl L. Schultz, Admiral, U.S. Coast Guard, Commandant: I concur with the intent of this recommendation. The Coast Guard agrees that information regarding openings that could lead to downflooding should be available to the vessel's master. Since 1992, U.S. vessels subject to 46 CFR 170.170 and SOLAS are required to have aboard comprehensive damage control information (see SOLAS 90 regulations II-1/23, 23-1, & 25-8; and SOLAS 2009 regulation II-1/19), in accordance with MSC. I /Circ.1245, "Guidelines for Damage Control Plans and Information to the Master." Further, U.S. ships constructed after 1992 are required to have similar information in their stability booklets in accordance with 46 CFR 170.110, including guidance for the safe operation of the vessel under normal and emergency conditions. As such, we consider the requirements addressed in this recommendation to already be in effect for U.S. vessels built since 1992 that are subject to SOLAS. However, the International Maritime Organization (IMO) decided not to apply these standards retroactively. With respect to vessels constructed before 1992, we believe that the most expeditious means to provide appropriate damage control information is for the company to include appropriate operational procedures in the vessel's SMS. The Coast Guard has addressed this matter in the recently promulgated supplemental flag State guidance regarding the development and implementation of SMSs. 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.