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Safety Recommendation Details

Safety Recommendation M-17-038
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: Update the guidance in Navigation and Inspection Circular 4-77 (Shifting Weights or Counter Flooding During Emergency Situations), based on the circumstances of the El Faro accident, to include a warning that actions by ship personnel intended to correct a list can produce dangerous results if roll-on/roll-off cargo is already adrift and water has reduced the coefficients of friction for lashed cargo.
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: During the accident voyage, El Faro’s cargo hold flooded, sending cars (RO/RO cargo) adrift, and sustained starboard windheel. The captain changed course to put the wind onto the vessel’s opposite side, intending to switch the list to port. At the same time, he attempted to correct the list by shifting water between the ramp tanks. Those actions resulted in a rapid shift to a port list. Our investigation report pointed out that NVIC 4-77 was developed in response to an accident related to bulk cargo stability, and it encourages captains to make every effort to determine the cause of a vessel’s list before taking corrective action. It also gives specific guidance for vessels carrying bulk cargo. The El Faro accident shows that the guidance in NVIC 4-77 is applicable to RO/RO container (RO/CON) cargo ships, and that attempts by ship personnel to correct a list, such as course changes and counter-ballasting, can produce dangerous results if cargo is already adrift. In addition, we pointed out that the risk of lashing failure and subsequent cargo shift increases if wet decks have reduced the friction between RO/RO cargo and the deck. We issued Safety Recommendation M-17-38 because we concluded that NVIC 4-77 would benefit from specific guidance tailored to RO/RO and RO/CON vessels. We note that you regard the existing guidance in NVIC 3-89, Guidelines for the Presentation of Stability Information for Operating Personnel and NVIC 4-77 to be sufficient, and you do not plan to make any further revisions to satisfy this recommendation. Please reconsider the need for specific guidance in NVIC 4-77 tailored to RO/RO or RO/CON vessels. Pending your taking the action discussed in Safety Recommendation M-17-38, it 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, NVIC 3-89 (Guidelines for the presentation of stability information for operating personnel) includes a recommendation to the Master with respect to list: "You should make every effort to determine the cause of any list of the vessel before taking corrective action." NVIC 4- 77 recommends, "that the stability information provided to the masters of all vessels should include guidance on the dangers of shifting weights or counter ballasting when a vessel experiences a list due to cargo shift or suspected water in cargo." The Coast Guard considers this existing guidance sufficient. 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.