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Safety Recommendation Details

Safety Recommendation M-17-062
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 AMERICAN BUREAU OF SHIPPING: Enhance training of your surveyors to ensure that they are properly qualified and supported to perform effective, accurate, and transparent vessel surveys, meeting all statutory and regulatory requirements.
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: American Bureau of Shipping (Open - Acceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: American Bureau of Shipping
Date: 2/4/2019
Response: Our investigation of El Faro’s sinking found a number of problems with the US Coast Guard’s (USCG’s) Alternate Compliance Program (ACP), in which the El Faro was enrolled. Under the ACP, an authorized classification society, such as the ABS, must develop a US supplement that addresses areas where current USCG requirements are not embodied in the class rules or international conventions, or, in the case of international conventions, areas that require interpretation by a flag administration. The supplement, combined with the class rules and international conventions, is equivalent to a US regulation. Our investigation found that some inspectors and surveyors were unfamiliar with the supplements. We also discovered cases where ABS surveyors found and documented safety concerns during surveys of the El Faro, but there was no timely response to these concerns. We issued Safety Recommendation M 17 62 as a result of our conclusion that the ACP did not effectively ensure that vessels meet the safety standards required by regulations, and that many vessels enrolled in the program are likely to be operating in substandard condition. We note that all newly hired surveyors must attend instructor-led training during their first year of hire. Every 3 years after that, all surveyors must complete a 5-day refresher training program, which you last updated in April 2018. In addition, all surveyors complete an annual, web based training course on statutory regulation and ABS rule changes. We further note that you took action to satisfy this recommendation after we announced it on December 12, 2017, when we adopted our report on El Faro’s sinking, but before we formally issued Safety Recommendation M-17-62 to you on February 7, 2018. As of February 1, 2018, you now require that all surveyors attending main propulsion boiler repairs must be certified for boiler surveys. In addition, you require that all surveyors and auditors complete a refresher training course about International Association of Classification Societies Procedural Requirement 17, “Reporting on deficiencies possibly affecting the implementation of the ISM Code on board during surveys.” Finally, we note that you are currently preparing a new USCG ACP training course that will be required for surveyors and auditors after the USCG releases the new ACP navigation and inspection circular (NVIC) 2-95 Change 3. This training course will be further updated after the single US supplement focused on critical systems is implemented. We understand that you monitor surveyors and auditors once every 2 years and evaluate their qualifications annually. On February 1, 2018, you implemented the following policy changes related to these activities: • A principal surveyor or surveyor-in-charge must attend special surveys of hulls that are 25 years old or older. • Beginning at 10 years old, US-flagged vessels enrolled in ACP, the Maritime Security Program (MSP), or MSP Select must be evaluated by two qualified surveyors for each subsequent annual survey and special survey. • Each port office is required to hold a monthly survey meeting to discuss survey issues. • You are currently verifying the accuracy of the data contained in each vessel survey status. The revisions that you made on February 1, 2018, partially satisfy this recommendation. Pending completion of your new USCG ACP training course that will be required for surveyors and auditors, and verification of each vessel’s survey status, Safety Recommendation M-17-62 is classified OPEN--ACCEPTABLE RESPONSE.

From: American Bureau of Shipping
To: NTSB
Date: 5/2/2018
Response: -From J. Riva, Vice President and Chief Surveyor: ABS Surveyors (includes both Surveyors and Auditors) have been formally educated to at least a bachelor’s degree level and/or hold a professional license. This prerequisite knowledge together with the training and certification ABS administers to its Surveyors provides for the capable and sound rendering of classification and statutory certification and services within their level of work responsibility. ABS only uses exclusive Surveyors or exclusive contracted surveyors to conduct classification and statutory surveys. This is in accordance with the IACS (International Association of Classification Societies) procedural requirements. Training programs assigned to all Surveyors are determined by corporate departments (e.g., Health, Safety and Quality & Environmental, Human Resources, Corporate Classification, Compliance, etc.). All new hire surveyors must attend instructor led training program during first year of hire. Subsequently each 3 years all Surveyors must complete a refresher five day training program that consists of instructor led training and web based courses. This training program was recently updated and the new version was implemented in April 2018. ABS has mandatory training that all Surveyors must complete based on training type and hire date. ABS also uses required training that are prerequisite for specific process certifications. For career development ABS also has other training programs. Furthermore ABS requires all Surveyors to complete an annual web based training course, on statutory regulation and ABS Rule changes The ABS training meets or exceeds the following IACS Procedural Requirements: 1) PR 7, “Procedure for the Training and Qualification of Survey and Plan Approval Staff”. This Procedural Requirement defines the common training and qualification requirements for survey and plan approval staff in accordance with the requirements of IMO Resolutions A.739(18) and A.789(19), ISO 9001:2008 and ISO/IEC 17020:2004, as amended. 2) PR10. “Procedure for the Selection, Training, Qualification and Authorization of Marine Management Systems Auditors” The ABS Quality and Environmental Management Manual (QEMS) meets applicable regulatory requirements, in accordance with the requirements of the ISO 9001:2015, ISO 14001:2015, and EN ISO/IEC 17020:2012 and International Maritime Organization Resolution MSC.349(92) Code for Recognized Organizations (RO Code), in addition to the IACS QSCS and IACS Resolutions. The ABS Quality System incorporates survey procedures and work instructions which ensure that the necessary steps associated with the survey and certification requirements of the relevant rules and international conventions are carried out in a controlled, verifiable manner. ABS qualification system for Surveyors contains over 190 certifications. Each Surveyor, before providing services under these procedures, must first be trained; and upon satisfactorily completing the process is, subsequently, certified to the process in question. As a minimum, proficiency in a given process instruction is established by performing the applicable task at least once, in accordance with the controlling procedure, as on-the-job training under the supervision of a person who has satisfied the requirements of the particular task in question IMO “Revised Guidelines on the Implementation of the International Safety (ISM) Code By Administration”, Res. A. 1071 (28) specifies the following requirements for the ISM Code auditors. These IMO guidelines were considered and adopted in IACS Procedural Requirements No 10 and have been implemented in the ABS ISM Code auditor training and certification procedures. There are at least two areas where ABS requirements for auditor selection, training, and certification exceeded both IMO Res A. 1071 (28) and IACS PR 10 requirements at the time of El Faro incident. For example: 1) IMO Res A. 1071 (28) requires that ISM auditors must have participated in at least 3 initial or renewal verifications. ABS requires that ISM Code auditors must participate in 4 audits out of which 3 audits must be initial or renewal. Additionally, ISM Code auditors are required to participate in at least one company audit and one shipboard audit towards their qualification requirements. ABS does not have a separate (lower tier) qualifications for annual, intermediate and interim audits as allowed by the IMO Guidelines, but requires that the all ISM auditors be qualified for initial and renewal verifications regardless of types of verifications carried out. 2) ABS complies fully with IACS PR 10 requirements. Additionally, ABS requires that all ISM auditor candidates have minimum of two years of marine operations/shipboard experience. This ABS additional requirement is waived only on a case-by-case basis based on the prior experience of the auditor candidate and availability of auditor resources. Based on the NTSB recommendation, ABS has required that all Surveyors attending repairs of main propulsion boilers, must be also certified for boiler surveys effective 1 February 2018. In addition, ABS has required all Surveyors and Auditors to complete a PR17 refresher training course. Furthermore, ABS is preparing a new USCG ACP training course that will be required for Surveyors and Auditors, upon the U. S. Coast Guard releasing the new ACP NVIC 2-95 Change 3. This training course will be further updated upon implementation of the single U. S. Supplement focused on critical systems. ABS has confirmed to the USCG, that we will have Surveyors available to attend training at Yorktown, including the Steam Plant Inspection course (USCG Safety Recommendation 25) and Advance Journeyman Inspection Course (USCG Safety Recommendation 26). To date, ABS has not been invited to attend these courses. To verify the performance of Surveyors and auditors, ABS conducts monitoring once every two years and evaluates surveyor/auditor qualifications annually. ABS Policy Changes implemented on 1 February 2018: 1) Commencing at special survey of hull associated with 25 years of age, a Principal Surveyor/Surveyor- in-Charge must attend during the special survey for all self propelled vessels. 2) For U. S. Flagged vessels enrolled in ACP, MSP, or MSP Select, ABS requires two qualified Surveyors to attend commencing at 10 years of age and then each subsequent annual survey and special survey. 3) ABS requires each port office to hold a monthly survey meeting to discuss survey issues. 4) ABS is in the process of verifying the accuracy of the data contained in each vessel survey status (estimated completion date is March 2019). In regards to the ABS Steel Vessel Rules, ABS made the following Rule changes to improve the safety of ABS classed vessels: Jan 2015: 3-3-1/7 Damage Control Information: ABS Rules required all new ships to have plan showing clearly for each deck and hold and boundaries of the watertight compartments, the openings therein with the means of closure and position of any controls thereof, and the arrangements for the correction of any list due to flooding, is to be permanently exhibited or readily available on the navigation bridge for the guidance of the officer in charge of the vessel. Feb 2018: 7-3-2/5.1.7(a): ABS Rules require that all vessel undergoing Special Survey commencing at 15 years of age, the structural ventilation ducts and down flooding ducts are to be internally examined. Feb 2018: 7-3-2/1.1.17: ABS Rules require cargo space fire dampers to be examined during annual surveys. Feb 2018: 7-3-2/5.1.18: ABS Rules require all cargo space fire dampers to be examined and operational tested during each special survey (every 5 years). Feb 2018: 7-3-2/5.1.1: ABS Rules require a survey planning document to be developed for all vessels other than barges, prior to the commencement of each Special Survey of Hull. Based upon the above, ABS confirms that we have further enhanced the training of our Surveyors to ensure that they are properly qualified and supported to perform effective, accurate, and transparent vessel surveys, meeting all statutory and regulatory requirements. If you have any questions or require clarifications please contact the undersigned.

From: NTSB
To: American Bureau of Shipping
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 is one issued to the American Bureau of Shipping, which can be found on page 253 of the report. The NTSB is vitally interested in this recommendation because it is 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 this recommendation. When replying, please refer to the safety recommendation by number.