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Safety Recommendation Details

Safety Recommendation M-17-066
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.: Ensure that damage control plans and booklets are aboard all your load-lined vessels and that officers and crewmembers are trained in their use.
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: TOTE Services, Inc.
To: NTSB
Date: 10/10/2019
Response: -From Jeff Dixon, President, TOTE Services, LLC: As noted in our prior letters, TOTE concurs with the intent of this recommendation. Our Orca Class and Marlin Class vessels have damage control plans and booklets that are approved and implemented, satisfying the latest standards and regulations. In addition, as part of the ongoing LNG conversion process on our two Orca Class vessels, damage control plans and booklets are updated and approved to the latest standards by the Coast Guard and the Classification Society. NORTH STAR completed the update and transition to a new damage control plan and booklet in February 2018, in conjunction with Phase I of its LNG conversion. Similarly, MIDNIGHT SUN completed her review and implementation for her current condition and will subsequently transition to the new damage control plans and booklets following Phase I of the LNG conversion process, anticipated to occur in December 2019. TOTE Services’ training matrix has been changed to include mandatory professional damage control training. This training is held at the American Maritime Officers Union training facility in Dania Beach, FL for select officers and at the Seafarer's International Union School of Seamanship in Piney Point, MD for certain unlicensed crew. This company requirement, for senior officers and high-level unlicensed crew members, is designed to educate those responsible for conducting drills and training on our TOTE vessels in current Damage Control techniques and practices. We have set a period of five years for this to be repeated. The initiatives described above are in addition to, and are being carried out in conjunction with, other new safety initiatives at TOTE. This includes our newly instituted annual emergency response drills in which ABS' Rapid Response & Damage Assessment Team ("RRDA"), vessel personnel, and TOTE's shoreside managers all participate. See further discussion below regarding Recommendation M-17-73.We believe Recommendation M-17-66 has been fully and appropriately addressed.

From: NTSB
To: TOTE Services, Inc.
Date: 3/11/2019
Response: You expressed disappointment that our El Faro report did not mention that your SMS contained various damage-control checklists, including ones that address flooding, that are applicable to all the vessels you manage. Familiarization with these damage-control checklists is part of your quarterly tracked training program, which you said was up to date and performed on board the El Faro throughout the year before the sinking occurred. However, our report did point out that the El Faro’s SMS included an emergency preparedness manual but did not incorporate guidance or procedures specific to the El Faro. We issued Safety Recommendation M 17-66 based on our conclusion that if a damage-control plan had been available and the crew was trained in its use, the crew would have been better able to promptly plan for and address the flooding scenario encountered during the accident. You wrote that the El Faro’s SMS contained damage control checklists that the crew was trained to use, yet the checklists were not used during the accident and the crew was apparently unfamiliar with them. SOLAS requires dry cargo ships built after 1992 to have a damage-control plan, those built after 2005 to also have a damage-control booklet, and those built after 2009 to have an “information to the master” section. We note that currently all TOTE-owned vessels were built after 1992, and are therefore are currently required to have approved damage-control plans and booklets on board. Regarding crew training for damage-control procedures, you plan to review existing training materials and requirements in your SMS and implement changes where needed. At a minimum, you plan to institute an annual flooding/damage-control drill for the crews of all your vessels. You are also evaluating the use of an observer team to ride TOTE-owned ships and conduct refresher damage-control training. For all vessels that you manage but do not own and that were built before 1992, you are contacting the vessel owners to present our recommendation, and you will recommend that they develop appropriate, ship-specific damage-control procedures, similar to a damage-control plan. Please tell us in future updates to this recommendation how many of the ships that you manage that were built before 1992 have developed and implemented damage-control plans that are carried on board, as well as the steps that you will take to ensure that the crews you provide will be trained in these damage-control plans when available. Because all of the vessels you now own were built after 1992, and are therefore required to have a damage-control plan, you have satisfied the first part of Safety Recommendation M 17 66 for ships that you own. To satisfy this recommendation, you must complete your review of your damage-control training and implement needed revisions, direct the owners of ships built before 1992 that you manage to develop damage-control plans, and let us know how you will ensure that your crews receive training in these damage-control plans. Pending completion of those actions, Safety Recommendation M-17-66 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 prior letter, TOTE concurs with the intent of this recommendation. Our Orca Class vessels are having their damage control plans and booklets updated and approved to the latest standards, by the Coast Guard and the Classification Society, in conjunction with the LNG conversion process. The NORTH STAR completed its update to damage control plan and booklet in February 2018, in conjunction with Phase I of its LNG conversion. Similarly, the MIDNIGHT SUN will complete its update to damage control plan and booklet when it goes through Phase I of the LNG conversion process, anticipated to occur in December 2019. We do not expect any further changes will be required to the damage control plans and stability booklets for the Orea vessels related to completion of the LNG conversion process. The MARLIN CLASS vessels have damage control plans and booklets approved and implemented, satisfying the latest standards and regulations. In regard to training, we have previously provided a description of our damage control drill and training program, all of which meets or exceeds applicable regulatory requirements. We continue to review these training materials and requirements in our SMS, to further enhance the readiness of our crews. This process is ongoing. As you know, in its Final Action Memorandum to the investigation, the Coast Guard declined to establish new damage control training and drill requirements for commercial cargo vessels, but instead concluded that existing general regulations in this area, contained in 46 CFR and the STCW Convention, were adequate. There is also no indication the Coast Guard plans to propose such requirements or standards to the International Maritime Organization. Accordingly, there are no specific standards or regulations in place that we are aware of, applicable to cargo vessels, upon which we can model drills and exercise requirements. As you may be aware, however, there are such damage control drill standards and requirements in SOLAS, that go into effect for passenger vessels in 2020, implemented through IMO resolution MSC.421(98). We are in the process of evaluating these requirements and standards, to determine how they may be applied for our cargo vessels to enhance the effectiveness of our existing damage control drills and training program. Additionally, we have identified supplemental damage control training administered by the Seafarer's International Union affiliated Harry Lundburg School of Seamanship in Piney Point, MD and the American Maritime Officers affiliated Star Center, and are implementing a program to send the Master, Chief Mate, Chief Engineer, 1st Asst. Engineer, Bosun, and Electrician to this training. The initiatives described above are in addition to, and are being carried out in conjunction with, other new safety initiatives at TOTE. This includes our newly instituted annual emergency response drills in which ABS' Rapid Response & Damage Assessment Team ("RRDA"), vessel personnel, and TOTE's shoreside managers all participate. See further discussion below in regard to Recommendation M-17 -73. We will keep you apprised of our progress in completing this effort.

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. For vessels built after 1992 managed by TOTE (which includes vessels owned by TOTE-affiliated entities), those vessels currently have approved damage control plans and booklets implemented onboard, meeting the latest standards. In fact, the Orca vessels recently had their damage control plans and booklets updated to the latest standards, in conjunction with recent shipyard periods. Further, the NTSB’s report does not mention that TOTE’s SMS contained various damage control checklists, including checklists that address flooding, applicable to all vessels TOTE manages. Under TOTE’s SMS, though not specifically required by law, familiarization with these damage control checklists is part of TOTE’s quarterly tracked training program. The documentation shows that this quarterly familiarization training was up-to-date, and performed onboard EL FARO throughout 2015. In regard to training, we intend to conduct a review of existing training materials and requirements in the SMS, in regard to damage control and response, and implement changes where needed. At a minimum, though not required by law or regulation, we anticipate instituting an annual flooding/damage control drill for all vessels owned by TOTE-affiliated entities that would include the involvement of our outside technical support team (Rapid Response & Damage Assessment Team (“RRDA”)), appropriate shoreside managers, and vessel personnel. This is discussed further below, in connection with Recommendation M-17-73. We are also exploring the use of an observer team concept to ride TOTE-owned ships and conduct refresher damage control training. For all vessels TOTE manages that were built before 1992, we are contacting the vessel owners to present this recommendation, and to recommend that they consider performing a risk assessment and develop appropriate, ship-specific damage control procedures, similar to a damage control plan, and that they explore the possibility of meeting current damage stability standards. 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.