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Safety Recommendation Details

Safety Recommendation M-17-059
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 INTERNATIONAL ASSOCIATION OF CLASSIFICATION SOCIETIES: Recommend to your members that any opening that must normally be kept open for the effective operation of the ship must also be considered a downflooding point, both in intact and damage stability regulations and in load line regulations under the International Convention on Load Lines.
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: International Association of Classification Societies (Open - Unacceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: International Association of Classification Societies
Date: 9/11/2019
Response: Thank you for your February 26, 2019, letter regarding Safety Recommendations M-17 53 through -61. We issued these recommendations to the International Association of Classification Societies (IACS) on February 7, 2018, as a result of our investigation of the October 1, 2015, sinking of the US cargo vessel SS El Faro in the Atlantic Ocean, northeast of Acklins and Crooked Island, Bahamas. On May 2, 2018, the American Bureau of Shipping (ABS) wrote to us on your behalf regarding Safety Recommendations M-17-53 through -61. As we mentioned in our February 4, 2019, letter, we understand that you believe that, because these recommendations address flag related matters and statutory requirements, it is more appropriate that the International Maritime Organization (IMO) respond to them, and they should be forwarded to the US Coast Guard (USCG). The USCG, being the US representative to the IMO, would then propose flag actions or changes to the present regulations based on its evaluation of the recommendations. We agreed that IMO action is needed, which is why, in our El Faro report, we also issued Safety Recommendations M 17 21 to 23, 25 to 27, 29, and 30 to the USCG, recommending that it propose to the IMO the same actions that M-17-53 to 55 and -57 to -61 recommend. As we pointed out, we issued Safety Recommendations M-17-53 to -61 to ensure that your member classification societies were aware of our El Faro report and could take the recommended actions, if they chose to do so, without waiting for the IMO. Since our February 4, 2019, letter to you, the ABS has sent us two additional letters—one on February 4, 2019, and one on March 4, 2019—addressing the recommendations listed above on your behalf. We note that you have taken action to address Safety Recommendation M-17-56, which we will discuss first. Regarding these recommendations, the ABS wrote that “many of the recommendations are either closely related to or laterally addressed in SOLAS or MCS [IMO Maritime Safety Committee] Circulars.” Although these guidance documents might address some aspect of our recommendations, the ABS did not provide any analysis or explanation to support its contention that the guidance was relevant. Please explain how these guidance materials satisfy the intent of our recommendations. Further, the ABS contends that you do not have the authority to compel members to implement specific requirements, because members can declare “documented reservations.” We believe that argument represents a misunderstanding about what these recommendations are asking you to do. Safety Recommendations M-17-53 through -61 all begin by asking the IACS to recommend that your members take some action. None of our recommendations asks you to require that your members do something. The ABS also states that your members cannot implement our recommendations “ . . . because unilateral development and implementation (ahead of IMO) . . . could put IACS members in direct legal conflict with contractual obligations . . . towards delegating governments.” We do not expect your member classification societies to undertake actions that would be illegal or put the classification society at risk for other reasons. Although we understand your concern, we believe the classification societies are in the best position to evaluate how they should respond to the issues identified in our recommendations to you. We also find these arguments perplexing, as you did take action in response to M-17-56 by issuing a new requirement to your member classification societies, which, in fact, exceeded our request. It stands to reason, then, that if you were able to address M-17-56, you should also be able to take action on M-17-53 through -55 and M-17-57 through -61. In our February 4, 2019, letter, we asked you to clarify this inconsistency, but we have not received an explanation. Please tell us why you could respond to M-17-56 but not to the other eight recommendations. Finally, we note that, according to the ABS, you maintain that the IMO is the correct body to address these recommendations, and that you plan to take no further action until the USCG or IMO initiate work. We are disappointed by this response and we respectfully ask that you reconsider your position; we believe the issues discovered during our investigation of the El Faro sinking are critical and relevant to all classification societies. Pending action to address these issues, Safety Recommendations M-17-53 through M-17-55, and M-17-57 through M-17-61 are classified OPEN—UNACCEPTABLE RESPONSE.

From: International Association of Classification Societies
To: NTSB
Date: 3/4/2019
Response: -From Gary Horn, Vice President and Chief Surveyor, American Bureau of Shipping: Further to the ABS letter of 4 February 2018 on the above subject, ABS advises that as IACS has previously commented, recommendations M-17-53 through 55 and 57 through 61 are either Flag related matters or statutory requirements more effectively addressed through the IMO Maritime Safety Committee (MSC). Many of the recommendations are either closely related to or laterally addressed in SOLAS or MSC Circulars, as shown in the following list: M-17-53: SOLAS II-1/26; M-17-54: MSC.1/Circ.1245; M-17-55: SOLAS II-1/13-1; M-17-57: SOLAS II-1/35-1; M-17-58: SOLAS II-1/35-1; M-17-59: MSC.1/Circ.1537; M-17-60: MSC.1/Circ.1245; M-17-61: SOLAS II-1/35-1. IACS noted in the report and as indicated in your letter of 4 February 2019 the NTSB also made recommendations on these matters directly to the USCG; and therefore, IACS offered support to the USCG efforts at the IMO. IACS also points out that as an organization IACS does not have the authority to require its Members to uniformly implement all IACS-agreed resolutions and members may declare documented reservations. Additionally, if IACS and the IMO work independently and in parallel on these matters differences between IACS and IMO requirements could develop. These two points will create very undesirable confusion and uneven application within the industry. Furthermore, IACS members in their role as recognized organizations (ROs) cannot accommodate the NTSB request because unilateral development and implementation (ahead of IMO) of requirements that are subject of international treaties which Governments have ratified and put into their laws could put IACS members in direct legal conflict with contractual obligations as ROs towards delegating Governments. ROs have no legal power to implement requirements that could be considered different to the existing national or international laws, without acceptance of flag States. Therefore, IACS continues to maintain that the IMO is the correct body to address the NTSB recommendations listed above, and no further action from IACS will be taken until USCG and/or IMO initiates work.

From: International Association of Classification Societies
To: NTSB
Date: 2/26/2019
Response: -From Robert Ashdown, Secretary General: Thank you for your email and letter of 4 February 2019 which was forwarded to me by Mr. Gary Horn, Vice President, Regulatory Affairs, American Bureau of Shipping, and I hereby acknowledge receipt of the same. As you are aware, IACS' long-standing policy is for the 'concerned classification society' to initiate discussions within the Association on matters arising from accident investigation bodies and also to act as the principal point of liaison (see www.iacs.org. uk/media/4028/guidelines-on-marine-accidEtnt".'investigation-reports. pdf). It is for these reasons that IACS advice on NTSB Recommendations M-17-53 through 55 and 57 through 61, were communicated to you via ABS. I understand that ABS have also responded directly to you in relation to your letter of February 4 referenced above. I am pleased to inform you that ABS have already initiated further discussions in IACS in relation to the points raised in your letter of 4 February and we will, via ABS, respond in due course with the collective view of the Association. We will endeavour to send our detailed reply, via ABS, as soon possible but please appreciate the consultation process necessary in a member-led organisation may mean that this will take some time.

From: NTSB
To: International Association of Classification Societies
Date: 2/4/2019
Response: We note that the IACS member societies reviewed these recommendations and concluded that, because they address flag-related matters or statutory requirements, it is more appropriate that the International Maritime Organization (IMO) respond to them, and they should be forwarded to the US Coast Guard (USCG). The USCG, being the US representative to the IMO, would then propose flag actions or changes to the present regulations based on its evaluation of the recommendations. We agree that IMO action is needed, which is why, in our El Faro report, we also issued Safety Recommendations M 17 21 to 23, 25 to 27, 29, and 30 to the USCG, recommending that it propose to the IMO the same actions that M-17-53 to 55 and -57 to -61 recommend. We issued Safety Recommendations M-17-53 to -61 to the IACS to ensure that your member classification societies were aware of our El Faro report and can take the actions that we recommended without waiting for the IMO. In our experience, IMO action takes a very long time to complete, and we are unsure if the USCG will propose that the IMO take the actions that we believe are necessary to address the safety issues identified in our investigation. We note that the IACS member societies discussed our report and recommendations, and that, should the United States prepare the recommended revisions to the regulations and submit them to the IMO, as we recommended to the USCG, the IACS is prepared to offer its support, cooperation, and assistance. However, we reiterate that the IACS member societies should take the recommended actions without waiting for the IMO. Pending completion of the recommended actions, Safety Recommendations M-17-53 to -55 and M 17 57 to -61 are classified OPEN--ACCEPTABLE RESPONSE.

From: International Association of Classification Societies
To: NTSB
Date: 2/4/2019
Response: -From Gary Horn, Vice President, Regulatory Affairs: Reference: (1) ABS letter to the NTSB dated 2 May 2018. (2) NTSB letter to IACS dated 4 February 2019. (3) NTSB Marine Accident 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, PB2018-100342, Notation 57238, Adopted December 12, 2017. Further to the ABS letter of 2 May 2018 on the above subject (Ref. 1), and with reference to the NTSB letter to IACS this date (Ref. 2), as well as report (Ref. 3), ABS would like to advise you of the IACS action taken as follows. Regarding recommendation M-17-56, upon review of the NTSB report IACS decided to add a new unified class requirement for the protection from impact on seawater supply piping below the waterline in all cargo holds. This was covered by adding a new Section 13 to the existing IACS Unified Requirement (UR) related to piping, UR P2 “Rules for piping design, construction and testing” which will come into effect 1 January 2020. Although this document is publicly available on the IACS website www.iacs.org.uk, a copy of this UR and the related History File and Technical Background covering the new section 13 are attached for your ready reference. The IACS advice given on the rest of the NTSB Recommendations M-17-53 through 55 and 57 through 61 remain as indicated in the ABS letter of 2 May 2018 (Ref. 1). However, reference is again made to the NTSB letter to IACS of this date (Ref 2), it is advised that the latest NTSB comments will be reviewed by IACS and replied to by separate correspondence in due course. If you have any questions or require clarification, please contact the undersigned.

From: International Association of Classification Societies
To: NTSB
Date: 5/2/2018
Response: THIS LETTER IS FROM THE AMERICAN BUREAU OF SHIPPING, NOT THE SAFETY RECOMMENDATION RECIPIENT THE INTERNATIONAL ASSOCIATION OF CLASSIFICIATION SOCIETIES: -From Gary Horn, Vice President, Regulatory Affairs, American Bureau of Shipping: Subject: Recommendations to IACS contained in the NTSB Report of the sinking of the El Faro References: (1) NTSB Marine Accident 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, PB2018-100342, Notation 57238, Adopted December 12, 2017 (2) IACS Guidelines on Marine Accident Investigation Reports (Feb 2014) Reference is made to the IACS e-mail to the NTSB dated 29 November 2017, please note that ABS is responding by separate correspondence to the NTSB following the guidance contained in Ref. (2). Further reference is made to the NTSB e-mail to ABS dated 7 February 2018. ABS has made IACS aware of the NTSB report Ref. (1), specifically the NTSB Recommendations M-17-53 through 61. ABS advises the NTSB that IACS member societies discussed these matters and concluded that since recommendations M-17-53 through 55 and 57 through 61 are Flag related matters or statutory requirements more effectively addressed through the IMO Safety Committee, accordingly each of these recommendations should be forwarded to the United States Administration for action in the IMO following SOLAS, Ch I, Reg. 21. The US via the U.S. Coast Guard would then propose Flag actions or any changes in the present regulations based on their evaluation of the recommendations. The US as an IMO Member State, would have to follow the IMO Guidelines on the organization and method of work of the Maritime Safety Committee and the Marine Environment Protection Committee and their subsidiary bodies (MSC-MEPC.1/Circ.5) to submit a new work program item to IMO to propose such revisions. IACS would like to advise that should the US prepare such changes to the regulations and submit them to the IMO, IACS is prepared to offer the US and IMO our support, cooperation and assistance. With regard to recommendation M-17-56, IACS is currently reviewing the NTSB report and recommendations with a view toward developing a new unified class requirement for the protection from impact on seawater supply piping below the waterline in all cargo holds.

From: NTSB
To: International Association of Classification Societies
Date: 2/7/2018
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. 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 nine issued to the International Association of Classification Societies, which can be found on pages 252–253 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.