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Safety Recommendation Details

Safety Recommendation M-17-042
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 THE UNITED STATES COAST GUARD: At regular intervals, not to exceed 20 years, review all lifesaving appliances on inspected vessels that are required by Title 46 Code of Federal Regulations Part 199, and require compliance with current standards.
Original recommendation transmittal letter: PDF
Overall Status: Closed - Unacceptable Action
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: 4/30/2019
Addressee(s) and Addressee Status: USCG (Closed - Unacceptable Action)
Keyword(s):

Safety Recommendation History
From: NTSB
To: USCG
Date: 4/30/2019
Response: We note that you do not concur with this recommendation because when you improve the standards for lifesaving appliances, you determine the rule’s applicability based on the impact it has on new and existing vessels. You believe that retrospectively reviewing the entirety of 46 CFR subchapter W to repeat this analysis would add an undue and unnecessary administrative burden to your rulemaking process. As an alternative, you have initiated a concentrated inspection campaign (CIC) for all ships fitted with open lifeboats. The CIC will ensure that open lifeboats and their related launching appliances are maintained in good working order and ready for use. We do not regard your CIC as an acceptable alternate action because it will not ensure that lifesaving appliances on a ship comply with the standards in place for the previous 20 years; rather, it will simply ensure that less-safe lifesaving appliances, such as open lifeboats, comply with the now-obsolete standards in place when the ships were built. Nevertheless, you regard your action to address this recommendation complete. Accordingly, Safety Recommendation M-17-42 is classified CLOSED--UNACCEPTABLE ACTION.

From: USCG
To: NTSB
Date: 7/17/2018
Response: -From Karl L. Schultz, Admiral, U.S. Coast Guard, Commandant: I do not concur with this recommendation. When the Coast Guard promulgates regulations, we consider the impact on both new and existing vessels to determine the applicability of the rule. Depending on the cost-benefit analysis, this could include grandfathering or phasing in applicability for existing vessels. Conducting a retrospective review of the entirety of 46 CFR Subchapter W to repeat this analysis would add an undue administrative overhead to the rulemaking process. However, with regard to open lifeboats, the Coast Guard has initiated a Concentrated Inspection Campaign (CIC) on all ships fitted with open lifeboats. The purpose of the CIC is to ensure that open lifeboats and related launching appliance are maintained in good working order and ready for immediate use. The CIC will run from May 02, 2018 - May 01, 2019. A final report of the CIC will be made public via the Coast Guard Maritime Commons blog. I consider the Coast Guard's action on this recommendation complete and request that it be closed.

From: NTSB
To: USCG
Date: 2/7/2018
Response: 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 29 issued to the US Coast Guard, which can be found on pages 248–251 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. We encourage you to submit your response to correspondence@ntsb.gov. If it exceeds 20 megabytes, including attachments, please e-mail us at the same address for instructions. Please do not submit both an electronic copy and a hard copy of the same response.