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Safety Recommendation Details

Safety Recommendation M-17-036
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 vessels in ocean service (500 gross tons or over) be equipped with properly operating meteorological instruments, including functioning barometers, barographs, and anemometers.
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable 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 - Unacceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: USCG
Date: 4/30/2019
Response: We note that you believe it is unnecessary to mandate that oceangoing vessels carry meteorological instruments beyond those that are already recommended in SOLAS Chapter V, “Safety of Navigation,” Regulation 5, “Meteorological services and warnings.” Accordingly, you consider your action in response to this recommendation to be complete, and you have asked that the recommendation be closed. We point out that Arrangement 5.2.4, which contains the relevant recommendation in SOLAS V 5.2, states (with emphasis added) the following: to arrange for a selection of ships to be equipped with tested marine meteorological instruments (such as a barometer, a barograph, a psychrometer, and suitable apparatus for measuring sea temperature) for use in this service, and to take, record and transmit meteorological observations at the main standard times for surface synoptic observations (i.e. at least four times daily, whenever circumstances permit) and to encourage other ships to take, record and transmit observations in a modified form, particularly when in areas where shipping is sparse. The purpose of Regulation 5.2 is to arrange for ships at sea to report weather conditions and to provide weather forecasting information to mariners. However, the intent of Safety Recommendation M-17-36 is to ensure the crew of a ship at sea will have the weather observations needed to make informed decisions about the weather they are in and will encounter. We further point out that, although Regulation 5.2.4 lists several weather instruments, it does not mention an anemometer. Our El Faro investigation revealed that the ship’s anemometer was not working properly and had been nonfunctional for some time. A functional anemometer would have allowed the ship’s crew to compute the true wind direction and speed, and the captain would then have had additional information to determine the vessel’s position relative to Hurricane Joaquin. We issued Safety Recommendation M-17-36 based on our conclusion that the lack of a properly functioning anemometer deprived the captain of a vital tool for understanding his ship’s position relative to the storm. Please reconsider your decision not to take action on this recommendation. Pending a requirement that vessels in ocean service be equipped with properly operating meteorological instruments, including functioning anemometers, Safety Recommendation M-17-36 is classified OPEN--UNACCEPTABLE RESPONSE.

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. While we concur with the intent of this recommendation, we do not believe that mandated carriage of meteorological instruments, beyond that which is already recommended in SOLAS V-5.2, is necessary. 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.