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Safety Recommendation Details

Safety Recommendation M-17-037
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 Title 46 Code of Federal Regulations 170.110 (stability booklet) to require (1) stability instructions, guidance, or data on wind velocity used to calculate weather criteria; (2) list of closures that must be made to prevent unintentional flooding; (3) list of closures that must be made for an opening not to be considered a downflooding point; and (4) righting arm curve (metacentric height) table to note the angle at which initial downflooding occurs; also, add a windheel table for vessel full load displacement or the condition of greatest vulnerability to windheel.
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 issued this recommendation because a more comprehensive stability booklet than the one on board El Faro might have changed the course of events. If the vessel’s stability booklet had contained the specific information included in this safety recommendation, the captain might not have taken the route that brought him close to strong winds, or may have avoided the actions that placed the vessel in danger. Our El Faro report pointed out that you provide general guidance in Navigation and Inspection Circular (NVIC) 3 89 and 46 CFR 170.110, but the information we have recommended is neither specified nor required. We note that you have contracted with the National Academy of Sciences, Transportation Research Board, Marine Board to identify and recommend appropriate updates to 46 CFR subchapter S¬–Subdivision and Stability, which includes 46 CFR 170.110, and that you will consider the Marine Board’s recommendations when revising intact and damage stability standards. Pending revisions to 46 CFR 170.110, as recommended by the Marine Board, to address the issues in Safety Recommendation M-17-37, it 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 partially concur with this recommendation. An approved stability booklet is required to contain sufficient information to enable the master to operate the ship in compliance with applicable requirements (see 46 CFR 170.110( c ); 2008 IS Code section B/3.6.2; and the Code on Intact Stability, (A. 749(18), section 2.1.2)) Since 2003, ships have been required to have stability booklets that are modeled in accordance with the IMO Model Loading and Stability Manual (MSC/Circ.920). It prescribes each presented condition of loading to include a diagram of righting levers plotted against heel angle with wind or other heeling lever curves superimposed on the diagram as appropriate and that downflooding angles be tabulated against draft over the range of operating drafts with critical openings identified. Since 1992, SOLAS has required that comprehensive damage control information be provided aboard cargo ships (see SOLAS 90regulations11-1/23-1 & 11-1/25-8 and SOLAS 2009 regulation 11-1/19). U.S. ships built since 1992 are required to have similar information in their stability booklets in accordance with 46 CFR 170.110. This information includes a listing of elements (i.e. closures .. . etc.) considered to be vital to the survival of the ship and its crew. For ships not currently subject to the requirements, the Coast Guard promulgated a Work Instruction on April 16, 2018 to provide supplemental flag state guidance regarding the development, implementation, and verification of SMSs, which includes provisions for evaluating risks and developing contingency plans for emergency shipboard situations (e.g. heavy weather procedures, damage control information, closure of watertight and weathertight openings, etc.). In addition, the Coast Guard has contracted with the National Academy of Sciences, Transportation Research Board, Marine Board, to identify and recommend appropriate updates to 46 CFR Subchapter S - Subdivision and Stability, which includes 46 CFR 170.110. The Coast Guard will consider the independent recommendations of the Marine Board when determining any necessary revisions of intact and damage stability standards. 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.