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Safety Recommendation Details

Safety Recommendation M-17-031
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: Publish policy guidance to approved maritime training schools offering bridge resource management courses to promote a cohesive team environment and improve the decision-making process, and specifically include navigational and storm-avoidance scenarios.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable 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 #: MAR-17-01
Accident Date: 10/1/2015
Issue Date: 2/7/2018
Date Closed:
Addressee(s) and Addressee Status: USCG (Open - Acceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: USCG
Date: 4/30/2019
Response: We note that you plan to issue the recommended guidance to ensure that BRM courses cover the importance of building a cohesive team environment, and that you also plan to provide guidance to schools that includes this outcome in the leadership and teamworking and the leadership and managerial skills courses. You do not, however, believe it is appropriate to specifically address extreme weather as part of a BRM course; instead, you plan to provide guidance about extreme weather to schools with approved courses in meteorology. We are concerned that you may not fully understand this recommendation as it relates to navigational and storm-avoidance scenarios. Although storm-avoidance and mitigation training is more appropriately covered in a meteorology course, Safety Recommendation M-17-31 asks that storm-avoidance scenarios be discussed in BRM training. Our El Faro investigation revealed that, although several junior officers expressed concerns about the ship’s planned course in relation to the hurricane, they did not voice their concerns assertively to the master, and the master did not respond appropriately when they asked him to come to the bridge. We believe the El Faro scenario is an effective and powerful example of the breakdown of BRM principles during an extreme weather scenario. Please reconsider your decision not to include an extreme weather scenario in BRM training, such as the one that occurred on the El Faro, to illustrate the need for and consequences of a BRM breakdown. Pending publication of the recommended policy guidance, Safety Recommendation M-17-31 is classified OPEN--ACCEPTABLE RESPONSE.

From: USCG
To: NTSB
Date: 7/17/2018
Response: -From Karl L. Schultz, Admiral, U.S. Coast Guard, Commandant: I concur with this recommendation. The Coast Guard will issue guidance to ensure bridge resource management (BRM) courses cover the importance of building a cohesive team environment. We will also provide guidance to schools to include this outcome in the leadership and teamworking course, and leadership and managerial skills course. Additionally, the Coast Guard understands the importance of training mariners in extreme weather avoidance. However, we do not believe it is appropriate to specifically address this issue as part of BRM courses. Instead, the Coast Guard will provide guidance to schools with approved courses in meteorology. I will keep the Board informed of the Coast Guard's action on this recommendation.

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.