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Safety Recommendation Details

Safety Recommendation M-17-046
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: Modify guidance and training for marine inspectors to ensure that voyage data recorder annual performance tests include the replacement of locator beacons prior to expiration and that audio used to evaluate quality is recorded while a ship is under way using its main propulsion unit.
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: Our El Faro investigation found that the audio quality of the VDR data was either poor or unusable, depending on the channel. Among the audio quality issues was the repeatedly captured noise pollution from a metal curtain rail that hung in the chart table area. This noise pollution interfered with or obscured many crew conversations essential to understanding the safety issues associated with the vessel’s sinking. The noise was continuous while the vessel was in motion, but would not have been present when the ship was pierside, which is where bridge audio and VDR performance testing typically occurs. A second problem with the VDR that we encountered was related to the locator beacon, which did not function after the ship sank. When investigators arrived at the site of El Faro’s sinking on October 23, 2015, the VDR locator beacon could not be detected. After several days on site, it became clear that investigators would not locate the El Faro by listening for the locator beacon. As mentioned in our accident report, at El Faro’s most recent annual VDR performance test in December 2014, the battery for the acoustic locator beacon was still current. However, although the battery would expire in May 2015 (less than 6 months later), the technician inspecting the VDR did not replace the battery or take any action to ensure it was replaced before the expiration date. At the time of El Faro’s sinking, the battery had already been expired for 4 months, which likely explains why the locator beacon was not operating. We concluded that the annual performance test for El Faro’s VDR was inadequate because the technician did not replace the locator beacon’s battery, even though it would expire before the next performance test. We also concluded that recovery of El Faro’s VDR was greatly hampered because the beacon was silent during the search. We note that you do not concur with this recommendation because VDRs must already meet required annual performance standards and be tested in a specific manner by specially trained and qualified technicians. We understand these requirements, and we note that the “normal operations” referred to in the IMO’s MSC standard 333(90) imply the ship is underway and using its main propulsion system when its VDR audio quality is evaluated. However, despite these specific requirements, and regardless of the technician’s specialized training and qualifications, we found serious shortcomings with the required annual inspection of El Faro’s VDR. We issued this recommendation because these shortcomings impeded our investigation, and hindered our ability to identify safety issues associated with the vessel’s sinking. Given the findings of our investigation that support this recommendation, please reconsider your decision not to take action to address it. Pending completion of the recommended action, Safety Recommendation M-17-46 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 do not concur with this recommendation. The requirements for Voyage Data Recorders (VDRs) and related performance standards provide specific requirements that VD Rs should meet and the manner in which they should be tested. Further, the required annual performance testing is performed by specially trained and qualified technicians. 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.