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Safety Recommendation Details

Safety Recommendation M-17-069
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.: Conduct an external audit, independent of your organization or class society, of your entire safety management system to ensure compliance with the International Safety Management code and correct noted deficiencies.
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
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)

Safety Recommendation History
From: TOTE Services, Inc.
Date: 10/10/2019
Response: -From Jeff Dixon, President, TOTE Services, LLC: As stated in our May 7, 2018 letter, TOTE concurs with the intent of this recommendation. We contracted class society DNV-GL to conduct a formal audit of our safety management system and vessel operations, and an assessment of our overall company processes to find areas of improvement. The executive summary of this assessment is provided as an enclosure. The assessment began on August 20, 2018 and concluded on November 1, 2018 with a formal report of findings presented to the TOTE Services executive team. The assessment of TOTE’s safety management system utilized a custom DNV protocol that spanned over 12 unique sections. The assigned auditors used a combination of interviews, observation of operations and ship condition, and documentary verification. As part of the vessel operations assessment portion, DNV staff rode two TOTE Maritime vessels (one Marlin, one Orca) as they transited between their US ports of call. Two MARAD vessels in ROS were also visited and assessed. We have attached the Executive Summary of DNVs formal report as enclosure (1). The assessor issued six findings, three minor non-conformities and three observations, during the assessment. The company issued OPSMEMO A-139 in response to the DNV report. We have attached OPSMEMO A-139 for information as enclosure (2). The OPSMEMO, which was sent to the entire fleet, included the six findings, a root cause analysis, corrective action plans and the preventative actions for each. All items were addressed, and all corrective action changes were completed by December 2018. These actions are also formally recorded in our deficiency tracking program known as the “Action Tracker.” We believe Recommendation M-17-69 has been fully and appropriately addressed.

From: NTSB
To: TOTE Services, Inc.
Date: 3/11/2019
Response: We note that your document of compliance (DOC) certifies that your SMS fully complies with the ISM code, and your SMS has been fully certified since 1997, including the 5 year renewal cycle since that time. In addition to the 5-year DOC renewal audits, the American Bureau of Shipping (ABS) has completed annual DOC audits, and you have conducted internal office shoreside audits via a third-party contractor. We further note that at the time that you sent your May 7, 2018, letter, you were identifying an auditor to conduct the recommended audit that you planned to start in mid-2018. Please tell us when the audit began, and when it is scheduled to be completed. Pending that information, Safety Recommendation M-17 69 is classified OPEN--ACCEPTABLE RESPONSE.

From: TOTE Services, Inc.
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 the intent of this recommendation. We have previously described to you the many layers of auditing that our SMS already undergoes as a matter of routine practice, some of which includes auditing by independent third parties, and we do not repeat that description here. With that said, we agreed that there was value in having another fresh, independent examination of our SMS. In this regard, we contracted with DNV GL to perform an independent audit of our SMS, consistent with this recommendation. The shoreside SMS audit was completed in August 2018, and vessel audits were completed in September 2018. Initial feedback was substantive and positive, and we are awaiting final report submission. We will keep you apprised of our progress on this issue.

From: TOTE Services, Inc.
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. To put this recommendation in context, a brief description of the certifications already in place – and the audit mechanisms in place to ensure compliance -- is helpful. As a threshold matter, TOTE’s Document of Compliance (“DOC”) certifies that its SMS fully complies with the ISM Code. In fact, TOTE’s SMS has been fully certified by the Coast Guard and ABS since 1997. It is important to note that this DOC, with the five year reissue to TOTE on November 17, 2016, remains valid and nothing in the recently issued investigative reports changes that fact. In addition, though not required by law, TOTE’s SMS complies with the standards of ISO 9001 for quality assurance and ISO 14001 for environmental compliance. Thus, TOTE’s SMS at the time of the loss of the EL FARO (and to this day) fully complies with (and indeed exceeds) applicable international conventions (e.g. ISM Code, SOLAS Convention, etc.) and applicable U.S. legal requirements. In addition to the five year DOC renewal audit completed November 2016, annual ABS DOC audits were completed in February 2016, May 2016 (follow-up), and February 2018. Additionally, internal office shoreside audits were completed in November 2015, November 2016 and November 2017 (by a third party contractor). Prior to each external ABS audit, TOTE also utilized three separate contracted services to assist with additional reviews of the SMS, training, and audit preparation. This included assistance and advice provided by Det Norske Veritas (“DNV”) – a classification society independent of ABS with extensive ISM experience – thereby providing a fresh, independent examination of our safety systems. Also, in 2017 a consultant company was contracted to review and streamline the shoreside SMS which was subsequently released to the fleet in December 2017. These efforts continue, to ensure the safety of our operations going forward. Additionally, the lessons of EL FARO have resulted in increased industry oversight and focus, from both Coast Guard and ABS. Our observations of these increased efforts have been positive, with both providing greater and more detailed program review and positive validation of our operating SMS. TOTE has implemented numerous lessons learned over the past two years, and we believe we are on the leading edge of addressing these new developments and recommendations. Our focus is continuing to refine and enhance our own SMS, while aggressively evaluating any potential additional lessons that can be gleaned from the Marine Board of Investigation (“MBI”) and NTSB reports. We have also introduced a new streamlined, electronically managed SMS and document management module utilizing ABS’ online NS Enterprise platform. These initiatives and improvements strengthen ease of shipboard SMS implementation and enable real time updates to the Safety, Quality & Environmental Management Manual. We have also engaged in targeted efforts to evaluate portions of our system, including a recent Saltchuk initiative to review BRM and Heavy Weather Procedures across the marine operating companies. Notwithstanding the significant additional examination of our procedures, and positive improvements to safety that have been made, we acknowledge the NTSB’s recommendation on this issue, and believe there is positive value in a third-party auditor that can lend objective feedback as to the effectiveness of TOTE’s follow-up, prioritization, and actions to adopt MBI/NTSB findings and recommendations. We are, therefore, in the process of identifying an auditor to conduct this review, and are targeting audit commencement in the mid-2018 timeframe. We will keep you apprised of our progress on this issue.

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 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.