Transcription of Sinking of US Cargo Vessel SS El Faro
1 Sinking of US Cargo Vessel SS El Faro Atlantic Ocean, Northeast of Acklins and Crooked Island, Bahamas October 1, 2015 Accident report NTSB/MAR-17/01 PB2018-100342 National Transportation Safety Board NTSB/MAR-17/01 PB2018-100342 Notation 57238 Adopted December 12, 2017 Marine Accident report Sinking of US Cargo Vessel SS El Faro Atlantic Ocean, Northeast of Acklins and Crooked Island, Bahamas October 1, 2015 National Transportation Safety Board 490 L Enfant Plaza SW Washington, DC 20594 National Transportation Safety Board. 2017. Sinking of US Cargo Vessel SS El Faro, Atlantic Ocean, Northeast of Acklins and Crooked Island, Bahamas, October 1, 2015 .
2 Marine Accident report NTSB/MAR-17/01. Washington, DC. Abstract: 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).
3 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.
4 ; and TOTE Services, Inc. The NTSB is an independent federal agency dedicated to promoting aviation, railroad, highway, marine, and pipeline safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The NTSB makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews.
5 The NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB regulation, accident/incident investigations are fact-finding proceedings with no formal issues and no adverse parties .. and are not conducted for the purpose of determining the rights or liabilities of any person. 49 Code of Federal Regulations section Assignment of fault or legal liability is not relevant to the NTSB statutory mission to improve transportation safety by investigating accidents and incidents and issuing safety recommendations. In addition, statutory language prohibits the admission into evidence or use of any part of an NTSB report related to an accident in a civil action for damages resulting from a matter mentioned in the report .
6 49 United States Code section 1154(b). For more detailed background information on this report , visit the NTSB investigations web page and search for NTSB accident number DCA16MM001. Recent publications are available in their entirety at the NTSB website. Other information about publications may be obtained from the website or by contacting: National Transportation Safety Board, Records Management Division, CIO-40, 490 L Enfant Plaza SW, Washington, DC 20594, (800) 877-6799 or (202) 314-6551. Copies of NTSB publications may be downloaded at no cost from the National Technical Information Service, at the National Technical Reports Library search page (this product number is PB2018-100342).
7 For additional assistance, contact: National Technical Information Service, 5301 Shawnee Road, Alexandria, VA 22312, (800) 553-6847 or (703) 605-6000 (see the NTIS website). NTSB Marine Accident report i Contents Figures ..v Tables .. viii Acronyms and Abbreviations .. ix Executive Summary .. xiii 1 Factual Information ..1 Introduction ..1 Accident Narrative ..4 Vessel Information ..30 Classification and Inspection ..31 Construction and Arrangement ..31 Propulsion System ..35 Electrical Generation and Distribution Fuel and Lubricating Oil ..37 Steering System ..43 Bilge and Fire Systems ..43 Maintenance ..46 Electronic Navigation Equipment.
8 52 Wind Sensors and Barometers ..53 Internal Communication ..54 Cargo Information ..55 Loading ..55 Types ..57 Securing ..58 National Cargo Bureau Review ..61 Modeling ..62 Safety Management System ..63 Injuries ..64 Wreckage ..64 Personnel Information ..74 Deck Officers ..75 Engineering Officers ..79 Supernumeraries ..82 Port Engineer ..84 Work and Bridge Resource Management ..85 Waterway Information ..87 NTSB Marine Accident report ii Meteorological Information ..90 Atlantic Hurricane Season 2015 ..90 Publicly Issued Hurricane Information ..92 Weather Information Accessible to El Faro ..95 Weather Data from Other Sources.
9 102 Tracking Errors ..104 Simulations ..107 Astronomical Data ..107 Survival Factors ..108 Emergency Response ..108 Lifesaving Equipment ..114 Emergency Lifeboat Standards and Regulations ..128 Conventional vs. Freefall Lifeboats ..130 Personal Locator Beacons ..131 Position Format ..131 Stability Information ..132 Concepts ..132 Changes in Vessel s Configuration ..133 Assessment of Vessel s Stability ..137 Methods of Assessing Stability ..137 Loading Condition at Departure ..141 Load Line ..142 Watertight Integrity ..143 Damage Control Plan for Flooding ..147 Rapid Response Damage Assessment Program ..149 Postaccident Analysis of Stability, Structures, and Sinking .
10 150 Dynamic and Forensic Sinking Analysis ..158 Operational and Management Information ..159 Company History ..159 Corporate Organization ..160 Company Operations ..162 Other Information ..166 Coast Guard Alternate Compliance Program ..167 General Provisions ..167 Targeted Vessel List ..168 ABS Surveys ..169 Coast Guard Examinations ..170 Tests and Research ..171 Fuel Oil Analysis ..171 Rogue Wave Analysis ..172 Inmarsat-C Mobile Earth Station Operation ..173 Previous NTSB Broadcasting of Position Data by Hurricane Forecasting ..174 Other Information ..176 NTSB Marine Accident report iii Actions Since Accident.
