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Safety Recommendation Details

Safety Recommendation M-17-067
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.: Require senior officers to receive formal training approved by the manufacturer in all functions found in installed stability programs, including damage stability modules.
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 stated in our May 7, 2018 letter, TOTE concurs with this recommendation. We conduct Senior Officer seminars every 18 months for our TOTE Maritime Masters and Chief Engineers. When available we open attendance to our Senior Officers from our MSC and MARAD managed vessels. The training in stability programs and damage stability modules is conducted at every Senior Officer seminar. Since the second update we have completed two Senior Officer seminars that included CargoMax training by Herbert Engineering naval architects. In attendance were all TOTE Masters and Chief Officers and Masters from several of our Military Sealift Command vessels. These training sessions covered the damage stability functions of the CargoMax software and a discussion on the enhanced damage stability features that TOTE implemented into its CargoMax programs on our TOTE vessels. Similar CargoMax training has been provided to appropriate shoreside personnel from TOTE Maritime Puerto Rico who plan and assist with loading operations for the Marlin Class vessels. The new features for current lashing profile parameters on our ABS approved stability software were also included in this training. Finally, as outlined on TOTE vessels’ Emergency Station Bills, we have designated the Chief Mate as the Damage Control Officer. Designating the Chief Mate to stability duties allows the Master to concentrate on major emergency management, not a single aspect, during any damage control situation. Providing CargoMax and professional damage control training to our Chief Mates elevates their competency in assessing damaged stability situations and leading the damage control team to mitigate physical damage impacts to the vessel. We believe Recommendation M-17-67 has been fully and appropriately addressed.

From: NTSB
To: TOTE Services, Inc.
Date: 3/11/2019
Response: We note that you have implemented a formal CargoMax training program for appropriate TOTE deck officers assigned to your Marlin class vessels, and that you plan to institute a similar program for your Orca class vessels. We further note that you also intend to designate the chief mates of all of your vessels as damage control officers, and to ensure that all chief mates and masters are trained in the use of onboard damage stability features in CargoMax. Pending completion of these actions, Safety Recommendation M-17-67 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 stated in our letter dated May 7, 2018, TOTE concurs with this recommendation. As previously reported, we have implemented a formal CargoMax training program for appropriate TOTE deck officers assigned to our Marlin Class vessels, and we have instituted a similar program for the Orca Class vessels. Most recently, this training occurred at our Afloat Senior Officer's Conference held in September 2018, and the remaining officers will receive this training at the next Officer's Conference in November 2018. Two convenings of the senior officer conference are now held every eighteen months to facilitate training and collaboration among our officers. Similar CargoMax training has been provided to appropriate shoreside personnel from TOTE Maritime Puerto Rico, who assist with loading operations for the Marlin Class vessels. This occurred in March and June 2017. TOTE Maritime Alaska personnel do not input CargoMax data for the Orca Class vessels, and therefore those shoreside personnel do not receive such training. Finally, we are designating the Chief Mate, serving onboard all vessels owned by TOTE-affiliated entities, as the Damage Control Officer. In connection with this initiative, Herbert Engineering provided training on CargoMax Damage Stability module at our Senior Officer's Conference held in September 2018, and the remaining officers will receive this training at the next Senior Officer's Conference in November 2018. This training covers all of the Masters, Chief Mates, Chief Engineers, and 1st Asst Engineers for all vessels owned by TOTE-affiliated entities. 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 this recommendation. We have implemented a formal CargoMax training program for appropriate TOTE deck officers assigned to our Marlin Class vessels, and we anticipate instituting a similar program for the Orca Class vessels. Similar CargoMax training is being provided to appropriate shoreside personnel from TOTE Maritime Puerto Rico who assist with loading operations for the Marlin Class vessels. TOTE Maritime Alaska personnel do not input CargoMax data for the Orca Class vessels, and therefore those shoreside personnel do not receive such training. We also intend to have the Chief Mate of all vessels owned by TOTE-affiliated entities designated as a Damage Control Officer, and ensure the Chief Mate and Master are trained in the use of onboard damage stability features in CargoMax. The Chief Mate will be designated to assist the Master with damage control response/operations in the damage control plan or similar guidance onboard. The Chief Mate, rather than the Master, was chosen for this role to ensure the Master is fully dedicated to his or her broader leadership role in managing all aspects of vessel operations, safety, and casualty response. This capability is intended to supplement, rather than replace, the damage stability support rendered from TOTE’s shoreside resources and RRDA during a casualty response. 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.