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Safety Recommendation Details

Safety Recommendation M-17-041
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: Review and revise the policy for major conversion determinations to consider load line (maximum) draft as a principal vessel dimension.
Original recommendation transmittal letter: PDF
Overall Status: Open Acceptable Alternate 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 Alternate Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: USCG
Date: 4/30/2019
Response: We note that you are currently reviewing policies related to major conversion determinations and intend to update those policies where more detailed guidance is needed. However, you disagree that a vessel’s load line (maximum) draft should be considered a principle dimension. We further note that you consider your response to this recommendation to be complete and request that it be closed. We issued Safety Recommendation M-17-41 based on our conclusion that El Faro’s conversion to carry load-on/load-off containers, and the associated increase in draft, should have been designated a major conversion. Your review and revision of guidance and policies regarding major conversion determinations may be an acceptable alternate response if the revisions would have resulted in El Faro’s conversion being determined a major conversion. It is premature to close this recommendation until after you have completed your review and revisions, and shown that El Faro’s conversion would have been determined a major conversion. Until then, Safety Recommendation M-17-41 is classified OPEN--ACCEPTABLE ALTERNATE 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. The Coast Guard is currently reviewing policies related to major conversion determinations and intends to update those policies to address areas that would benefit from more detailed guidance. We do not, however, agree that a vessel's load line (maximum) draft should be considered a principle dimension as the term "dimension" is used in 46 USC 2101 (14a)(A). Changes in length, beam and depth best reflect the degree to which a vessel's dimensions are physically altered by a conversion. Alterations in carrying capacity are better quantified by changes in deadweight tonnage than by changes in maximum load line. A load line "dimension" can be altered with little or no physical modification of a vessel, as with the addition or removal of ballast, optimization of compliance with stability criteria, minor changes in compartmentation affecting stability, minor changes to the watertight and/or weathertight envelope, etc. Whether or not alterations of a vessel constitute a major conversion, any significant load line reassignment would be accompanied by verification of compliance with appropriate stability and structural strength standards. 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.