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Safety Recommendation Details

Safety Recommendation M-17-039
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: Conduct a complete review of the Alternate Compliance Program to assess the adequacy and effectiveness of the program.
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 chartered a third-party oversight reform team (TPORT) to review the ACP. The review concluded that your oversight of some ACP elements was ineffective, and highlighted various policy gaps and data-management inconsistencies. The TPORT developed new policies related to documenting deficiencies, installed new verification and monitoring techniques for vessels and authorized classification societies, provided new interpretations and oversight protocols related to SMSs, and reconfigured its data management system to better track vessel deficiency data. The TPORT has also initiated modifications to your Office of Commercial Vessel Compliance to create a dedicated team of oversight experts to manage alternate inspection programs that rely on third-party services. Pending completion of these revisions, Safety Recommendation M-17-39 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 chartered a Third Party Oversight Reform Team (TPORT), and has completed the recommended review regarding the adequacy and effectiveness of the ACP. The review concluded that Coast Guard oversight of certain elements of the ACP was ineffective, highlighted various policy gaps, and data management inconsistencies. Over the last 6 months, TPORT has promulgated several new policies related to the documentation of deficiencies, installed new verification and monitoring techniques for vessels and Recognized Organizations, new interpretations and oversight protocols related to SMSs, and reconfigured its data management system to better track vessel deficiency data. Finally, the TPORT has laid the foundation to modify the Coast Guard's Office of Commercial Vessel Compliance (CG-CVC) to create a dedicated team of oversight experts to manage alternate inspection programs that rely on third party services. 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.