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Safety Recommendation Details

Safety Recommendation M-17-073
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 shoreside management and vessel senior personnel with training in the Rapid Response Damage Assessment program and standard operating procedures, to include requirements to conduct annual drills and submit departure stability conditions for each vessel on each voyage.
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. TOTE Services formalized Safety Management System requirements to conduct annual RRDA exercises with all our TOTE owned vessels. These exercises encompass damage and emergency situations that bring together vessel, shoreside, and RRDA staff. They are held continuously throughout the year with all vessels completing at least one drill annually. Our Safety Management System has been updated to include specific instructions for TOTE-owned vessels to submit departure stability reports to the RRDA before going to sea. Regarding your request that we notify our external vessel owners who are not enrolled in the RRDA program, we have sent customer letters detailing our recommendations post EL FARO, which included an overview of the RRDA program and recommended participation for commercial customers. Please note, for MARAD and MSC vessels, U.S. Navy Supervisor of Salvage and Diving (SUPSALV) provides Salvage and Marine Fire Fighting (SMFF) response for all vessels, as required by 33 CFR Part 155, Subpart I. In the event of an incident requiring response capability, MARAD & MSC will contract SUPSALV directly to provide SMFF services, followed immediately by a MARAD or MSC commitment of funds, in accordance with agreements in place. We believe Recommendation M-17-73 has been fully and appropriately addressed.

From: NTSB
To: TOTE Services, Inc.
Date: 3/11/2019
Response: We note that for all vessels that you own, you plan to introduce requirements into your SMS to conduct an annual drill in which the RRDA participates with shoreside and vessel personnel, and to institute procedures to submit departure stability conditions for each vessel on each voyage to the RRDA. We further note that, because it is up to vessel owners to enroll in the RRDA, for vessels that you manage but do not own, you will make your external customers aware of this recommendation. Please tell us if your external customers made arrangements to enroll their vessels in the RRDA. Pending completion of the revisions to your SMS, and you providing us information regarding your external customers’ response to this recommendation, Safety Recommendation M-17-73 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. ABS RRDA administered familiarizing training for appropriate shoreside managers in April 2018. This refresher training provided information and training regarding the purpose, capabilities, limitations, and general methodology of RRDA. In addition, in our SMS, we are formalizing an annual emergency response drill requirement in which RRDA, vessel personnel, and TOTE's shoreside managers all participate. We have also instituted procedures in our SMS that requires TOTE owned vessels to submit departure stability conditions for each vessel on each voyage. With respect to senior vessel personnel, this training occurred at our Senior Officer's Afloat Conference held in September 2018, and the remaining officers will receive this training at the next Senior Officer's Afloat 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. These training sessions also included the key shoreside Company President, Vice Presidents, Directors of Shipmanagement, Director of Fleet Safety, and many other safety and operations staff. We believe Recommendation M-17-73 has been fully and appropriately addressed.

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. However, as previously conveyed to the NTSB Investigator-in-Charge for the EL FARO accident investigation in our Supplemental Party Submission, we believe the Chairman, Nautical Operations Group, materially misconstrued both the capabilities and role of the RRDA. The RRDA service that TOTE subscribed to in 2015 was not intended to be used in a casualty involving a vessel that is in extremis and at risk of imminent sinking. Under TOTE’s SMS, the RRDA is also not intended to be utilized directly by vessel masters and crew, but instead this is a service that is intended to assist shoreside personnel in advising vessel masters during response and salvage operations. Use of the RRDA to provide meaningful assistance in the case of the EL FARO was, in retrospect, not feasible or practicable, given the timeline of the casualty and inherent limitations of RRDA. With that said, TOTE concurs with the idea of familiarizing vessel senior management with the purpose and general methodology of RRDA. After careful consideration of NTSB’s recommendation, and in conjunction with our review the Coast Guard’s findings on this issue, for all vessels owned by TOTE affiliated entities, we intend to implement requirements into TOTE’s SMS to: (a) conduct an annual drill in which RRDA participates with shoreside and vessel personnel, and (b) institute procedures to submit to RRDA departure stability conditions for each vessel on each voyage. We have already conducted one shipboard and shoreside drill. Any decision to enroll in the RRDA, or similar response capability, is within the purview of the vessel owner. Therefore, for vessels we manage that are not owned by TOTE-affiliated companies, we are contacting our external customers to make them aware of this recommendation. We will keep you apprised of our progress in completing this effort. We trust this initial response will apprise you of TOTE’s actions so far that are related to the NTSB’s safety recommendations to TOTE. Please let us know if you have any immediate questions or if the NTSB believes any further action is required with respect to those recommendations that TOTE believes it has adequately 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 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.