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Safety Recommendation Details

Safety Recommendation M-17-045
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 all personnel employed on vessels in coastal, Great Lakes, and ocean service be provided with a personal locator beacon to enhance their chances of survival.
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 disagree with your assertion that, at this time, a PLB does not provide the needed location accuracy to ensure that mariners in distress have an efficient and effective means of initiating an appropriate SAR response and providing an accurate location for rescue. Our El Faro accident report points out that available 406-MHz PLBs determine location accuracy within 3 miles using the 406-MHz satellite system, and have a low power homing beacon that transmits on the 121.5-MHz frequency to help locate someone in need of rescue when the SAR asset arrives. Further, as was also discussed in the report, newer 406 MHz PLBs use global positioning system (GPS) input to achieve a location accuracy of about 300 feet and nearly instant SAR notification when activated. Several manufacturers offer marine models of these PLBs costing between $300 and $400 that have been on the market for many years. We believe these devices are an available, affordable technology that ensures that mariners in distress have the most efficient means of alerting rescuers, initiating an appropriate SAR response, and providing an accurate location for rescue. Additionally, older, non-GPS-enabled beacons now benefit from the medium earth orbit search and rescue (MEOSAR) system, which can increase the location accuracy of non GPS enabled beacons. We note that you are very interested in ensuring mariners in distress have the appropriate tools to aid in their rescue; however, you do not believe that, at this time, a PLB provides the needed location accuracy for this purpose. We further note that you continue to explore other technologies to provide effective distress alerting and location information for SAR operations. Please reconsider your conclusion regarding the suitability of modern 406-MHz PLBs and further explain why you disagree that current PLBs provide sufficient location accuracy to ensure that mariners in distress have an efficient and effective means of initiating an appropriate SAR response. Pending a requirement that mariners use available SAR technologies, Safety Recommendation M-17-45 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 partially concur with this recommendation. The Coast Guard is very interested in ensuring that persons in distress have the most efficient means of alerting their distress, initiating an appropriate search and rescue (SAR) response, and providing responders with an accurate location for rescue. While at this time a personal locator beacon does not provide the requisite location accuracy for this purpose, we are continuing to explore other technologies to provide effective distress alerting and location in a modem SAR environment. 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.