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Safety Recommendation Details

Safety Recommendation M-17-072
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.: Provide formal and recurrent training to your deck officers on the public and commercial weather information systems provided on board each vessel to ensure that the officers are fully knowledgeable about all weather information sources at their disposal and understand the time delays in the information provided.
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 the intent of this recommendation. In your March 11, 2019 letter, you indicated that you wanted clarification regarding our recurring training on the BVS system. Specifically, you wanted clarification that it covers time delays and latency issues of BVS data, when compared to the public weather reporting services that are available onboard. TOTE has implemented a robust weather service training regime onboard all our managed vessels. We provide three different private weather services to our vessels including AWT (BVS), WRI Dolphin Online, and Jeppesen Weather Routing services. These paid services are in addition to readily available public weather services. Training on the use of our weather software systems that are used on our vessels primarily occurs during Senior Officer Seminars (every 18 months) and during bridge familiarization training for all new mates and masters. As a follow-up to our October 22, 2018 letter to you, we can confirm that training of senior officers on the use of our weather software systems occurred at our last Senior Officers conference held in November 2018. In accordance with our safety management system, the Bridge Resource Management section requires training on AWT (BVS), WRI Dolphin Online, and Jeppesen Weather Routing services for all deck officers quarterly. The training addresses variations between public weather products and private weather products. These differences are analyzed by the vessels Master and discussed with our paid weather routing service forecasters. Both our weather routing software’s have built-in visual indication for weather forecast recency and broadcast latency. Our WRI Dolphin service is web based and has broadband access to the latest forecasts based on the most up to date weather analysis. The BVS system operates both online and remote with weather data packets arriving to the vessel via email services. The software gives a visual indication on the screen that the mariner is viewing the latest data packet based on the latest forecast data. Likewise, the mariner is alerted if the data is not connected to the online system and according to broadcast schedules, he/she will know that the weather is either current or expired. All of these features -- and how they indicate recency/latency of the weather information -- are built into and addressed in the onboard training sessions required for all new and existing deck officers. We believe Recommendation M-17-72 has been fully and appropriately addressed.

From: NTSB
To: TOTE Services, Inc.
Date: 3/11/2019
Response: You expressed confusion as to why this recommendation asks for formal training programs on the use of “public” weather information systems, such as SAT-C, or NAVTEX, that are required to be on board your vessels. You pointed out that such formal training and certification is already required of licensed deck officers; you believe that these existing training and certification requirements are adequate and you do not plan to duplicate the training. As detailed in our El Faro report, at about 0500 on the morning of the accident, the El Faro bridge team was looking at two weather data reports that gave differing positions for the center of Hurricane Joaquin. The Bon Voyage System (BVS) report, which was downloaded at 0445 but was almost 12 hours old at that point, predicted the advanceable position of the storm’s center to the northwest of the vessel’s position, while the Inmarsat-C report (one of the publicly available reports), which was current as of 0446, reported the storm’s center directly east of the vessel’s position. At 0503, the VDR recorded the captain saying, “We’re getting conflicting reports as to where the center of the storm is,” but it appears that there was no recognition that the perceived conflict was due to the difference in valid times for the weather sources’ center positions for Joaquin. We issued this recommendation because decision-makers on board any vessel, as well as any shoreside support personnel, should be thoroughly familiar with weather information that is readily available to them, including the latency, or time delay, of the data. Although the El Faro’s crew had completed the required training on the use of public weather information sources available on the bridge, they appear to have not recognized that latency issues were the reason for the conflicting information they received. There were also issues with the officers understanding the capabilities and limitations of BVS and, as a result, they did not recognize the time delay in the BVS tropical cyclone information that was the source of conflict between it and the more current SAT-C information. We note that during 2018, BVS refresher training was given at your senior officer conferences. We further note that, after 2018, you will incorporate annual formal BVS training for all deck officers on TOTE-owned vessels. You are also advising clients whose vessels you do not own but manage, and whose vessels have weather-routing services delivered through existing contracts with third-party vendors, of the issue in this recommendation, and you are recommending they institute similar vendor-provided refresher training for personnel assigned to those vessels. Although we do not believe it is necessary to duplicate the already required training related to public weather information available on the bridge, we believe the El Faro sinking shows the need to remind mariners that latency issues may result in conflicting weather information. Please tell us if your BVS training includes time delays and latency issues, and how these compare to publicly available weather information. Pending an acceptable answer to that question, and confirmation that recurrent BVS training has been implemented, Safety Recommendation M 17 72 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 believes this Recommendation 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. For 2018, Bon Voyage System (“BVS”) refresher training will be provided by Applied Weather Technologies (“AWT”) at our Senior Officer Conferences. We hold Senior Officer Conferences periodically to provide a professional forum for senior officers outside of an onboard sailing cycle, in which shoreside management collaborate with and share information and best practices with our senior officers -- with the goal to better ensure the safety and efficiency of our operations. After the 2018 scheduled conferences, we will incorporate annual formal BVS training for all deck officers on TOTE owned vessels. For vessels not owned by TOTE-affiliated entities (e.g. Military Sealift Command), those vessels have weather routing services delivered through existing contracts with third party, government vendors. As such, we are advising these non-TOTE clients of this issue and are recommending they evaluate existing training support and, if appropriate, institute similar vendor-provided refresher training for vessel personnel assigned to those vessels. NTSB appears to have recommended that TOTE institute formal training programs on the use of weather information systems required to be onboard TOTE-managed vessels (i.e. “public” weather information systems, such as SAT-C, NAVTEX, etc). The NTSB appears to have overlooked that such formal training and certification is already required of licensed deck officers. Specifically, the STCW operational level training requirements include a 40-hour training course on meteorology, and management level (Chief Mate and Master) require an additional advanced meteorology course. Both of these training courses address the interpretation of various public weather information systems. While we acknowledge the NTSB’s recommendation in regard to “public” weather information systems, we are currently of the view that these existing training and certification requirements, already in place, are adequate and we do not intend to duplicate this training. We note that the Coast Guard did not recommend additional training in this regard. We believe Recommendation M-17-72 has been fully and appropriately addressed.

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.