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Safety Recommendation Details

Safety Recommendation M-17-065
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 TOTE SERVICES, INC.: Establish procedures for opening, closing, and logging all closures that make up a vessel’s watertight envelope while the vessel is at sea.
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: TOTE Services, Inc. (Open - Acceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: TOTE Services, Inc.
Date: 3/11/2019
Response: We note that all the cargo ships you currently own were built after 1992 and are subject to a Safety of Life at Sea (SOLAS) requirement that most watertight doors, access hatches, and external openings be fitted with open/closed indicators on the bridge. Therefore, you believe that your current arrangements and systems provide bridge personnel sufficient, real-time awareness of any watertight fitting being left open; consequently, you do not believe it necessary or appropriate to establish a separate procedure to log these fittings as closed or open. For these vessels, your focus will be limited to those watertight closures that are above the main freeboard deck that are not already required to have indicator lights. For vessels built before 1992 that you manage but do not own, you are informing your clients (the owners of these ships) of the issue and recommending that they consider installing open/closed indicator lights on the bridge for all watertight and weathertight fittings located above the uppermost watertight deck, or instituting logging procedures, or taking some combination of these two measures. Although we acknowledge that it is the responsibility of the ship owner to install indicator lights, we also believe it is your responsibility to develop and use procedures for logging the open/closed status of all watertight openings that do not have indicator lights. We issued this recommendation so that a ship’s crew could quickly determine if any watertight access doors or access hatch covers that are normally closed at sea are open or closed, regardless of when the ship was built. We agree that it is not necessary to log doors or hatches open/closed for which there is already a required indicator, but, as our El Faro report discussed, the SOLAS regulations state that “access doors and access hatch covers normally closed at sea, intended to ensure the watertight integrity of internal openings, shall be provided with means of indication locally and on the bridge showing whether these doors are open or closed [emphasis added].” We were concerned because the SOLAS requirement does not define “internal opening,” which introduces ambiguity and might allow for a hatch similar to the scuttles on the El Faro. Your plan to log the status of all “watertight closures that are above the main freeboard deck that do not already have indicator lights” will satisfy this recommendation, provided that it includes all watertight access doors and access hatch covers normally closed at sea, regardless of when the ship was built. Pending completion of your plan, Safety Recommendation M-17-65 is classified OPEN--ACCEPTABLE RESPONSE.

From: TOTE Services, Inc.
To: NTSB
Date: 10/22/2018
Response: -From Philip H. Greene, Jr., President, TOTE Services, Inc.: As noted in our initial response, TOTE concurs with the intent of this recommendation. All cargo ships constructed after 1992 managed by TOTE, which includes all vessels owned by TOTE-affiliated companies, are subject to regulations that require most watertight doors, access hatches, and external openings to be fitted with open/closed indicators on the bridge. As noted in our initial response, we believe these required arrangements and systems provide adequate real time awareness to bridge personnel to detect any degradation of watertight integrity due to a watertight fitting being left open, inadvertently or otherwise. TOTE has implemented updated Safety Management System ("SMS") provisions for maintaining watertight integrity on vessels it manages. These procedures require all watertight fittings, including deck scuttles and hatches, to be checked and secured before proceeding to sea, and to be checked at least daily while at sea to ensure they remain secured. The SMS further requires that information in regard to the status of watertight fittings be discussed during every watch turnover. In addition, if approaching heavy weather, the SMS contains written procedures, including ship specific heavy weather checklists and plans, that require the Chief Mate and Deck Department to ensure all doors, hatches, deck openings, vent covers, sounding pipes, and other watertight fittings are secured. With respect to watertight doors, under applicable regulations, watertight doors on cargo vessels must be closed while the vessel is underway, but may be temporarily opened when being used for passage of crew. However, there are exceptions to this general rule and certain watertight doors may be left open under limited conditions while underway. While TOTE's SMS has always generally required watertight doors to be kept closed while underway, the SMS did not fully address when exceptions may apply, and what procedures must be followed. After further examining this issue, we have instituted updated procedures in our SMS for opening, closing, and logging certain watertight doors, in an effort to further mitigate risk in this area. Under these new procedures, if a watertight door is to remain open for an authorized purpose while underway, the Master must provide explicit permission, a Job Hazard Assessment (JHA) form must be completed, and a log must be maintained on the bridge showing that the watertight door is open. Review of any watertight doors logged open has also been added as a watch relief item for bridge personnel. These updated procedures apply to all TOTE-managed vessels. We believe Recommendation M-17-65 has been fully and appropriately addressed.

From: TOTE Services, Inc.
To: NTSB
Date: 5/7/2018
Response: -From Philip H. Greene, Jr., President, TOTE Services, Inc. and Timothy Nolan, President, TOTE Maritime Puerto Rico: This letter acknowledges the e-mail of February 7, 2018, in which the Executive Secretariat, Office of the Managing Director, National Transportation Safety Board (“NTSB”) formally issued certain safety recommendations to TOTE Services, Inc. (“TOTE”). We have organized our responses below to correspond with the numbered safety recommendations to TOTE contained in the final report. Please note that all of the NTSB’s safety recommendations involve changes to vessel operations or capital improvements that exceed existing minimum standards set by law. Accordingly, as discussed further below, some recommendations, if adopted, may require capital improvements or other changes to vessels that are within the exclusive purview of the vessel owner, not the vessel operator. Accordingly, for vessels we manage that are not owned by one of our affiliated companies, we are contacting these external customers by letter to make them aware of these recommendations, so that they may consider these issues and initiate whatever changes they deem appropriate. Therefore, in many cases below, the response we provide only applies to the vessels that are owned by our affiliated companies. We try to make that distinction clear with respect to each recommendation. Additionally, please note that in our Supplemental Party Submission, submitted to the NTSB on January 11, 2018, we identified a number of factual errors that were stated on the record by certain staff at the NTSB’s Public Meeting. Our intent was for the public record to be clear, but many of the errors we raised were not corrected or otherwise addressed when the final NTSB report was published. In some cases below, we point out these errors, not to be argumentative, but to ensure implementation of the changes we are making to our safety procedures are put in their proper factual and operational context. TOTE Response: TOTE concurs with the intent of this recommendation. We are continuing to review our existing SMS procedures in regard to heavy weather, preparing the vessel for sea, and at-sea watch procedures. All cargo ships constructed after 1992 managed by TOTE, which includes all vessels owned by TOTE-affiliated companies, are required to meet damage stability requirements. In addition, existing regulations applicable to such vessels require that most watertight doors, access hatches, and external openings be fitted with open/closed indicators on the bridge. Given the regulations applicable to vessels built after 1992, we believe that these arrangements and systems provide sufficient, real time awareness to bridge personnel to detect any degradation of watertight integrity due to a watertight fitting being left open, inadvertently or otherwise. Therefore, we believe establishing separate procedures to log these fittings closed or open would not enhance awareness of bridge personnel, but would instead be redundant with no safety benefit. Our focus on these vessels, with respect to assessing the need for logging procedures, will be limited to those watertight closures that are above the main freeboard deck that do not already have indicator lights by regulation. For TOTE-managed vessels built before 1992, we are informing our external clients (i.e., MARAD and Military Sealift Command) of this issue, and are recommending that they conduct a risk assessment and consider the feasibility and safety benefit of installing open/closed indicator lights on the bridge for all watertight and weathertight fittings located above the uppermost watertight deck, instituting logging procedures, or some combination of these two measures. Since TOTE-affiliated companies do not own these vessels, any capital improvements necessary to make such changes is a decision to be made by those vessel owners. We will keep you apprised of our progress in completing this effort.

From: NTSB
To: TOTE Services, Inc.
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 10 issued to TOTE Services, Inc., which can be found on pages 253–254 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.