USCG releases El Faro final report

The US Coast Guard issued an official investigation report on cargo vessel El Faro, which sank along with its 33 member crew, in October 2015, becoming one of the worst maritime disasters in US history. The investigation report on El Faro cargo vessel found that the captain underestimated the strength of a hurricane and overestimated the ship’s strength on a trip between Florida and Puerto Rico. Also, ship’s owner, Tote Maritime Inc., had not replaced a safety officer and had violated regulations regarding crew rest periods and working hours.

The incident

At the time of the sinking, EL FARO was on a U.S. domestic voyage with a full load of containers and roll-on roll-off cargo bound from Jacksonville, Florida to San Juan, Puerto Rico.

As EL FARO departed port on September 29, 2015, a tropical weather system that had formed east of the Bahamas Islands was rapidly intensifying in strength. The storm system evolved into Hurricane Joaquin and defied weather forecasts and standard Atlantic Basin hurricane tracking by traveling southwest. As various weather updates were received onboard EL FARO, the Master directed the ship southward of the direct course to San Juan, which was the normal route.

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The Master’s southern deviation ultimately steered EL FARO almost directly towards the strengthening hurricane. As EL FARO began to encounter heavy seas and winds associated with the outer bands of Hurricane Joaquin, the vessel sustained a prolonged starboard list and began intermittently taking water into the interior of the ship. Shortly after 5:30 AM on the morning of October 1, 2015, flooding was identified in one of the vessel’s large cargo holds. At the same time, EL FARO engineers were struggling to maintain propulsion as the list and motion of the vessel increased. After making a turn to shift the vessel’s list to port, in order to close an open scuttle, EL FARO lost propulsion and began drifting beam to the hurricane force winds and seas.

At approximately 7:00 AM, without propulsion and with uncontrolled flooding, the Master notified his company and signaled distress using EL FARO’s satellite distress communication system. Shortly after signaling distress, the Master ordered abandon ship. The vessel, at the time, was near the eye of Hurricane Joaquin, which had strengthened to a Category 3 storm. Rescue assets began search operations, and included a U.S. Air National Guard hurricane tracking aircraft overflight of the vessel’s last known position. After hurricane conditions subsided, the Coast Guard commenced additional search operations, with assistance from commercial assets contracted by the vessel’s owner. The search located EL FARO debris and one deceased crewmember. No survivors were located during these search and rescue operations.

Conclusions – Probable Causes

TOTE did not provide the tools and protocols for accurate weather observations. The Master and navigation crew did not adequately or accurately assess and report observed weather conditions.

EL FARO Incurred a Severe Port List and Lost Propulsion : At 5:54 AM on October 1, the Master altered course to intentionally put the wind on the vessel’s starboard side to induce a port list and enable the C/M to access and close the Hold 3 starboard scuttle. This port list was exacerbated by his previous order to transfer ramp tank ballast to port, and resulted in a port list that was greater than the previous starboard list and a dynamic shifting of cargo and flood water.

The loss of propulsion resulted in the vessel drifting and aligning with the trough of the sea, exposing the beam of the vessel to the full force of the sea and wind.

The EL FARO crew did not have adequate knowledge of the ship or ship’s systems to identify the sources of the flooding, nor did they have equipment or training to properly respond to the flooding.

A lack of effective training and drills by crew members, and inadequate oversight by TOTE, Coast Guard and ABS, resulted in the crew and riding crew members being unprepared to undertake the proper actions required for surviving in an abandon ship scenario.

After 5:43 AM on October 1, the Master failed to recognize the magnitude of the threat presented by the flooding into the hold combined with the heavy weather conditions. The Master did not take appropriate action commensurate with the emergent nature of the situation onboard EL FARO, including alerting the crew and making preparations for abandoning ship.

When the Master made the decision to abandon ship, approximately 10 minutes before the vessel sank, he did not make a final distress notification to shore to update his earlier report to TOTE’s Designated Person Ashore that they were not abandoning ship. This delayed the Coast Guard’s awareness that EL FARO was sinking and the crew was abandoning ship, and impacted the Coast Guard’s search and rescue operation.

The cumulative effects of anxiety, fatigue, and vessel motion from heavy weather degraded the crew’s decision making and physical performance of duties during the accident voyage.

EL FARO’s conversion in 2005-2006, which converted outboard ballast tanks to fixed ballast, also severely limited the vessel’s ability to improve stability at sea in the event of heavy weather or flooding.

Although EL FARO’s open lifeboats met applicable standards (SOLAS 60), they were completely inadequate to be considered as an option for the crew to abandon ship in the prevailing conditions.

Recommendations

Among others, it is recommended that Commandant direct a regulatory initiative:

to review U.S. regulations, international conventions, and technical policy to initiate revisions to ensure that all ventilators or other hull openings, which cannot be closed watertight or are required to remain normally open due to operational reasons such as continuous positive pressure ventilation, should be considered as down-flooding points for intact and damage stability.
to eliminate open top gravity launched lifeboats for all oceangoing ships in the U.S.commercial fleet.
to require that a company maintain an onboard and shore side record of all incremental vessel weight changes, to track weight changes over time so that the aggregate total may be readily determined.
to require review and approval of software that is used to perform cargo loading and securing calculations.
to require that all Personal Flotation Devices on oceangoing commercial vessels be outfitted with a Personal Locator Beacon.
to develop a shipboard emergency alert system that would provide an anonymous reporting mechanism for crew members to communicate directly with the Designated Person Ashore or the Coast Guard while the ship is at sea.
to request that NOAA evaluate the effectiveness and responsiveness of current National Weather Service (NWS) tropical cyclone forecast products, specifically in relation to storms that may not make landfall but that may impact maritime interests.
to require that all cargo ships have a plan and booklets outlining damage control information.
to update 46 CFR to establish damage control training and drill requirements for commercial, inspected vessels.
to require electronic records and periodic electronic transmission of records and data to shore from oceangoing commercial ships.
to explore adding an OCMI segment to Training Center Yorktown’s Sector Commander Indoctrination Course for prospective officers who do not have the Prevention Ashore Officer Specialty Code, OAP-10.
to update NVIC 2-95 and Marine Safety Manual Volume II to require increased frequency of ACS and Third Party Organizations (TPOs) direct oversight by attendance of Coast Guard during Safety Management Certificate and Document of Compliance audits.
to establish and publish an annual report of domestic vessel compliance.
to implement a policy requiring that individual ACS surveyors complete an assessment process, approved by the cognizant OCMI, for each type of delegated activity being conducted on behalf of the Coast Guard.
to explore adding a Steam Plant Inspection course to the Training Center Yorktown curriculum.
to require that all existing cargo vessels meet the most current intact and damage stability standards.