Safety culture blamed in El Faro loss

NTSB staff discuss findings and recommendations resulting from its El Faro investigation. Credit: NTSB

Gaps in training and safety management oversight revealed a “weak safety culture” at ro-ro operator Tote Services that contributed to the sinking of the El Faro, according to federal investigators.

The determination was made at a day-long meeting on 12 December at the US National Transportation Safety Board (NTSB) in reviewing its investigation into the October 2015 disaster, which resulted in the deaths of the ship’s 33-person crew as they attempted to avoid Hurricane Joaquin while en route from Jackonsville, Florida to Puerto Rico.

The NTSB voted on 53 recommendations to address safety issues uncovered during the investigation, which could lead to extensive changes in vessel safety and lifesaving equipment requirements.

Among the 29 recommendations made to the US Coast Guard (USCG), which issued its own set of safety recommendations in October, were 11 that directed the agency to propose safety changes at the International Maritime Organization, including those aimed at preventing flooding in heavy weather.

Ten recommendations were made to Tote Services, and another 10 were directed towards the International Association of Classification Societies and ABS, El Faro’s class society.

“This report will be studied by mariners, young and old, for many years, and I’m confident that this tragedy at sea, and the lessons from this investigation, will help improve safety for future generations of mariners,” said NTSB chairman Robert Sumwalt during his opening remarks.

“Although El Faro and its crew should never have found themselves in such treacherous weather, that ship was not destined to sink. If the crew had more information about the status of the hatches, how to best manage the flooding situation, and the ship’s vulnerabilities when in a sustained list, the accident might have been prevented.” He added that while the decisions made by Michael Davidson, the ship’s captain, were important, “there’s also more to this accident”.

NTSB’s nautical group chairman Michael Kucharski asserted during the meeting that Tote Services did not have an effective training programme in place for its cargo stability or damage response equipment. In addition, “Tote did not ensure that El Faro had a properly functioning anemometer, which deprived the captain of a vital tool for understanding his ship’s position relative to the storm.”

In addition to recommending that Tote conduct an external audit of its entire safety management system to ensure compliance with the International Safety Management (ISM) code, NTSB recommended the company require that its vessels be equipped with properly operating meteorological instruments.

Jon Furukawa, who was group chairman for Survival Factors in the investigation, explained that open lifeboats were not allowed on US vessels delivered after 1986, but that older vessels could be exempted from the requirement if properly maintained. The El Faro was built in 1975.

“It is possible that some of the crew of El Faro might have survived if the ship had been outfitted with enclosed lifeboats”, which current regulations require, he said.

The NTSB recommended that the USCG require that open lifeboats on all US inspected vessels “be replaced with enclosed lifeboats that meet current regulatory standards, and freefall lifeboats where practicable”.

Decisions made by the ship’s captain also factored into the sinking of El Faro, the agency said.

Davidson’s last course alteration “took El Faro close to the eye of the hurricane”, stated Kucharski. “Therefore, staff believed the captain did not take sufficient action to avoid Hurricane Joaquin, and thereby imperiled the ship and its crew,” he said.

It recommended that Tote provide formal and recurrent training to deck officers on 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”.

Contact John Gallagher at and follow him on Twitter:@JohnAGallagher1

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