NTSB Cites Weak Safety Culture as a Factor in the Sinking of the El Faro

By JASON DEAREN | December 14, 2017

The owner of the sunken cargo ship El Faro had a weak corporate safety culture that contributed to the vessel’s demise and the deaths of 33 mariners, federal accident investigators said on Tuesday.

The National Transportation Safety Board said that as a company, TOTE Maritime, Inc. suffered from a lack of “critical” aspects of safety management and training, one of the many problems the board hopes to mitigate through the adoption of 53 draft safety measures it’s recommending as a result of its probe.

The board noted that the captain was relying on outdated weather information, using a system he hadn’t been formally trained on; that a hatch left open in the storm allowed flooding in a cargo hold, destabilizing the vessel; and that the crew had not been adequately trained to deal with flooding and other effects of harsh weather.

The El Faro lost engine power in a Category 3 hurricane while sailing from Jacksonville to San Juan, Puerto Rico and eventually sank in 15,000 feet (4,570 meters) of water near the Bahamas.

NTSB investigators said Capt. Michael Davidson was using outdated weather data as he dismissed multiple requests by his mates to take a slower, safer route. Davidson relied on an emailed weather product called the Bon Voyage System, which by design runs six hours behind online National Hurricane Center updates. Investigators believe, based on the captain’s decisions and comments recorded on the ship’s voyage data recorder, or “black box,” he wasn’t aware of the delay.

“Although up-to-date weather information was available on the ship, the El Faro captain did not use the most current weather information for decision-making,” NTSB investigator Mike Kucharski said at the board’s final meeting on the 2015 disaster, held in Washington, D.C. “The captain did not take sufficient action to avoid Hurricane Joaquin, thereby putting El Faro and its crew in peril.”

The board also said that the 40-year-old freighter’s open-top lifeboats would not have protected the crew, even if they had been able to launch them. The El Faro was legally allowed to carry lifeboats that expose people to the elements – just like the lifeboats on the Titanic and the Lusitania – due to safety-rule exemptions for older ships.

Whether the crew could have survived Joaquin’s punishing winds and high seas if the El Faro had been equipped with the closed-top lifeboats used by newer ships is unknown, but NTSB safety investigator Jon Furukawa said it could have helped crewmembers fighting for their lives.

“We believe that would’ve been the best method of departing the vessel under these conditions. It is still challenging, and we don’t know if they would’ve survived,” Furukawa said. “But enclosed lifeboats are the current standard and the El Faro did not have the current standard.”

The board is not only recommending closed-top boats for all merchant ships, but also that the entire industry require crewmembers to carry personal locator beacons to better locate them during marine emergencies.

The El Faro had an older emergency position-indicating radio beacon, or EPIRB, which did not transmit global position system coordinates, and that made locating the ship more difficult for search-and-rescue crews. Given the heavy weather, rescuers probably couldn’t have reached the ship any sooner, but the board believes the new requirement would help in future sea accidents.

“One marine tragedy can point to many improvements. After the RMS Titanic sank, the world responded with the International Convention for the Safety of Life at Sea, or SOLAS, which has saved countless lives,” Sumwalt said.

The board’s final report follows one issued by the U.S. Coast Guard on the second anniversary of the ship’s sinking. That report placed primary blame on Capt. Davidson, who they said underestimated the hurricane’s strength and overestimated the ability of the 40-year-old ship to withstand it.

The recorder caught the final hours of the ship’s increasingly desperate crew as they tried to save the El Faro and themselves. According to transcripts of recovered audio, the second mate asked the captain in their final moments if she could grab her life jacket, suggesting this fundamental safety measure wasn’t readily available on the ship’s bridge. The NTSB also determined that the captain’s call to abandon ship came too late.

The NTSB and Coast Guard also said TOTE violated safety regulations requiring the crew to be well rested. The company had not replaced a safety officer management position, and had stopped employing port helpers to safely load cargo. The Coast Guard found that El Faro’s crew had difficulty keeping up with the brisk loading pace required to keep the ship on schedule ahead of the storm.

The Coast Guard is seeking civil, not criminal, penalties against TOTE.

The NTSB’s recommendations are not law, but are used to guide industry changes or updates to existing safety procedures overseen by the U.S. Coast Guard and so-called “classification societies” like the American Bureau of Shipping, which conducts a large percentage of marine inspections on the Guard’s behalf. The recommendations also can be used by Congress to create new laws meant to improve safety.

Larry Brennan, a professor of maritime law at Fordham Law School and a retired U.S. Navy captain, said the NTSB’s recommendations are taken seriously, and could create a safer working environment for mariners in the future. He applauded the board’s call for a new lifeboat requirement.

“No one should use open boats in rough weather, or any weather,” Brennan said. “If the NTSB takes an aggressive course, they may be able to effectively change regulations and policies that will enhance safety at sea.”