PREAMBLE

Every American mariner is aware of the El Faro disaster, when a container and ro-ro ship sank in the middle of hurricane Joaquin outside the West Indies on October 1 2015 with the loss of all hands.

The accident was investigated by the National Transportation Safety Board (NTSB) of America with the co-operation of the US Coast Guard, and their report was published on December 12 2017. The US Coast Guard also produced a report which was published on September 24 2017.

The El Faro in its final configuration - TOTE.

 

To give us an idea of what the El Faro was to be faced with, I first of all quote from “The American Practical Navigator” known as “Bowditch” after its first author Nathaniel Bowditch which has been published for over 200 years. The description is of the approach of what is known as the “bar” of the hurricane.

With the arrival of the bar, the day becomes very dark, squalls become virtually continuous, and the barometer falls precipitously, with a rapid increase in wind speed. The center may still be 100 to 200 miles away in a fully developed tropical cyclone. As the center of the storm comes closer, the ever-stronger wind shrieks through the rigging, and about the superstructure of the vessel. As the center approaches, rain falls in torrents. The wind fury increases. The seas become mountainous. The tops of huge waves are blown off to mingle with the rain and fill the air with water. Visibility is virtually zero in blinding rain and spray. Even the largest and most seaworthy vessels become virtually unmanageable, and may sustain heavy damage. Less sturdy vessels may not survive. Navigation virtually stops as safety of the vessel becomes the only consideration. The awesome fury of this condition can only be experienced. Words are inadequate to describe it.

Bowditch goes on to describe the ways in which the worst of a hurricane can be avoided including stopping in order to determine what the next action should be, depending on the direction in which the hurricane is moving, and in an appendix to the NTSB report a variety of techniques to avoid the worst of hurricanes are described, none of them relying on weather forecasts, due to the lag between the filing of the information and the subsequent transmission.  

There has been much written in the American marine press about the accident, and discussions have taken place on the gCaptain website, to the point that, for a while, all threads in their discussions seem to have ended up with an exchange of views about the El Faro and whose fault the disaster was. Now, in May 2018, several books have also been written, none of them by professional mariners, which have been variously reviewed. 

So the question that is sometimes raised, a bit a below the one about why the captain did not come to the bridge when asked by his officers to do so, is should a merchant ship which is in class, and apparently conforms to the relevant IMO guidance, be able to survive in a hurricane? 

We old style seafarers might think that the primary requirement is that the shipmaster use his skill and judgement to avoid the worst of adverse weather, and if necessary take the appropriate action to minimise damage if accidentally caught up in it. But there still are things that make some merchant ships more vulnerable to loss than others. One is the fact that IMO guidance is applied to current newbuidings; very, very seldom is a new regulation applied retrospectively, so an old ship may be more vulnerable, and El Faro was 40 years old. Typically the requirement that ships be provided with enclosed lifeboats did not become an IMO requirement until 1985 – hence the El Faro had open boats.  Really supporting this view, the Coast Guard had, at the time of the disaster, been compiling a list of the 10% most vulnerable US flag ships which were part of the Alternative Compliance Program (ACP). The El Faro was on the list. 

Another likely problem is that of shifting cargo, particularly on vessels carrying wheeled vehicles, which have to be lashed, again in conformance to a standard, but still within the limits of what is possible on the ship. And finally we get to the reliability of the plant. Can the engine or engines be relied on to keep going in any situation?

So bearing these things in mind, even though the captain’s actions seem to be difficult to understand, maybe the ship should have survived. Both the reports extend to hundreds of pages, so they have been difficult to summarise, and inevitably I have had to leave out quite a bit of discussion and some conclusions, but hopefully what follows will tell you much of what went wrong, and why the ship sank.

THE SHIP

The El Faro was 790 ft long and 105 ft wide. It was propelled by a single fixed pitch propeller, powered by a steam turbine, giving it a maximum speed of 22 knots. It was a combined ro-ro/container ship built in 1975 as the Puerto Rico at the Sun Shipbuilding and Drydock company in Chester, Pennsylvania. In 1993 it was lengthened by 90 ft by the addition of Hold 2A, and was used to sail between Washington State and Alaska. In 2005/2006 it was further modified from a pure ro-ro into a ro-ro/container ship. Before this conversion wheeled vehicles were carried on deck as well as underdeck. After various periods of lay-up it commenced operating on the Jacksonville – Puerto Rico run after the scrapping of the El Morro in 2014. 

Vehicles were loaded by a ramp on the starboard side aft which accessed the “second deck” in stability terms “the uppermost continuous deck” which was therefore open forward to aft, although the engine room uptakes passed through it. Below this deck were five holds each with two decks. These were designated No1 tween and No 1 hold,  and so on except that No 5 only had a tweendeck. There were two ramps and an elevator, and watertight doors between the holds providing vehicle access. Also there were pedestrian accesses in the larger doors. If we had a question it would be, how is watertightness ensured between the uppermost continuous deck – the second deck and the third and fourth decks? Equally important in terms of survival was the ventilation system. It appears that the holds were ventilated by forced draught, the intakes in pods proud of the hull at second deck level, thence the air was propelled down into the lower holds and upwards through perforations into the third deck level where it would enter further trunking, leading to exhausts in the ship’s side at second deck level. The inlet vents were protected by watertight closures and exhaust apertures were protected by weathertight closures. There were numerous openings on the second deck, making it effectively self ventilating, and also vulnerable to water ingress. Although there is a lot in the various reports about the state of the ventilation system, in fact witnesses described the fact that the vents were NEVER closed except during fire drills, so whether the closures were effective or not is not material to the event. However, the fact that closures were provided made the conformance with the rules possible. The exhaust fire dampers come under some scrutiny on the USCG report. They were designated as “weathertight” even though the 1990 Load Line Technical Manual stated that fire dampers should not be considered as weathertight closures.

After the later conversion the ramps to the open deck were blocked off and provision made to carry a large number of containers three high; a total of 1414 TEUs. Other masters of the PONCE design ships described that after the conversions despite what was apparently an adequate GM, with a 0.5 foot safety factor added, they felt that the ships were “hanging” at the extent of the natural rolls in a seaway.

The main engines were provided with a lubricating oil system ( important to the investigation) which was intended to conform to ABS rules in that it should be able to operate with the ship listing at an angle of up to 15 deg. The lube oil sump which served the turbines and main reduction gears had a recommended operating level of 27”, and at the time of El Faro’s departure on its final voyage, the level was 24.6”.

The ship was provided with a bilge pumping system which could pump out any dry cargo space, and indicate the presence of water; also pertinent to the event was the presence of the emergency fire pump in No 3 lower hold, which was provided with its own overside suction with a manual valve. On either side of the steering gear aft were two “ramp tanks” which could be used to keep the ship level during loading, and had a part in subsequent events.

Amongst its available navigational equipment, the ship was provided with a Voyage Data Recorder (VDR) which was to become the central means of the investigation into the disaster. Also pertinent to the inquiry were the anemometers of which the ship was provided with two, at least one of which input information into the VDR. The officers did not consider that either worked.

At the time of the disaster there were 33 people on board, including a five man riding crew, there to prepare the ship for a return to Alaskan waters with a TOTE chief engineer in charge.

MODIFICATIONS.

Both the Coast Guard and the NTSB investigations have highlighted the modifications which took place to the ship, the first when the extra hatch was installed in 1993 which was determined to be a “major modification” in terms of the Coast Guard requirements, which would, if the ship had been engaged in international trade, have required the ship to be upgraded in line with the latest SOLAS requirements, but it was not engaged in international trade, and so the upgrade was not required. There-after, when the 2005/6 modifications were carried out, the Coast Guard initially designated the work as being a major modification, but the company appealed against the decision on the basis that the other ships of the class had already been similarly modified, and so the USCG reconsidered their ruling. This is despite the fact that the work resulted in the load line draught being two feet deeper than it had been before the work. How could this be possible, we might ask, and honestly I have been unable to find out how such arbitrary re-assignment of the load line could be carried out. Reading the regulations is not rewarding, so maybe it would take a naval architect to tell us how this could be done. 

THE COMPANY

The ship was owned by TOTE Maritime, Puerto Rico and operated by TOTE Services Inc. It was classed with ABS (The American Bureau of Shipping) an organisation which was authorised to carry out regulatory inspections on behalf of the US Coast Guard.

TOTE is a subsidiary of a company called Saltchuk which operates a diverse selection of companies. It used to operate three PONCE class vessels in Jones Act trade, but the El Morro had been scrapped. Prior to 2013 TOTE provided the ships with shoreside support personnel many of whom had marine qualifications, and who would interact with the masters in all aspects of the ship’s operations, but in 2013 the company re-organised, replacing the mariners with a single position of TSI Marine Operations Manager. The incumbent in the position at the time of the accident did not hold any marine qualifications according to one entry in the CG report. By 2015 TOTE had become a number of organisations, TOTE Maritime Puerto Rico TMPR, which owned the ships, which were managed by TSI, TOTE Shipholding Inc. During the period leading up to the accident much of the TOTE management was primarily engaged in the development of two new ships The Isla Bella and Perla del Caribe.The TSE Safety Department comprised of the Manager of Safety and Operations, who was the Designated Person Ashore (DPA) who had an assistant manager reporting to him. 

The company also employed “Port Engineers” who were mainly as described, people with an engineering background. They reported to the Director of Ship Management – Commercial, who was also a marine engineer.

From the Organogram the TOTE organisation appeared to be as follows:

  • TOTE Services President and CEO
  • Director of Labour Relations and Risk Management
  • VP Marine Ops Governmental
  • VP Marine Operations – Commercial
  • Director of Ship Management – Commercial Operations
  • Port Engineer El Faro
  • Unit Business Controller
  • Director of Safety and Services
  • Manager Safety and Operations (The DPA)
  • Asst Manager Safety and Property Management
  • Safety and Operations Coordinator (unfilled) 

The USCG report also suggests that the DPA position was held by the TSI Marine Operations Manager, a position which does not exist on the organogram, but there’s scope for errors here. There seems to be confusion as to his marine qualifications (see above) but it is likely that he held an Unlimited Master’s Licence.

THE REGULATORY FRAMEWORK.

The El Faro was inspected as part of the ACP, Alternative Compliance Program, where many of regulatory inspections are carried out by Class – in this case ABS. The process allows the classification society to carry out regulatory inspections on behalf of the Coast Guard. The one major difference is that the ships are required to conform to the SOLAS conventions, and so need to conform to the ISM requirements and be provided with a Designated Person Ashore. 

During 2015 ABS had carried out inspections on board the El Faro on seven occasions. The NTSB report notes that there were no qualified CG inspectors capable of inspecting steam vessels, due to the very limited number of steam ships still in service. The Coast Guard Vintage Vessel Centre of Expertise, who might have provided guidance had been discontinued in 2013. 

WEATHER FORCASTING

There is a lot said about how the weather forecasts made it to the ship, and the fact that the Bon Voyage System, the BVS, was only sent to the captain’s computer, and that he had to transfer it onwards to the bridge. There were actually some errors in the forecasting which might have placed the centre of the hurricane some distance from the ship, but honestly it makes no difference. Both the second mate and the third mate had determined that the ship was heading straight for the eye of the hurricane, and passed the information on to the captain who remained in his bunk. 

THE SAFETY MANAGEMENT SYSTEM

According to the USCG the company safety management system consisted of an Operations Manual – Vessel (the OMV) and an Emergency Preparedness Manual. The system lacked any risk assessment process, and any guidance as to how the vessels might deal with adverse weather, particularly hurricane avoidance. 

THE SEQUENCE OF EVENTS.

The report on the sequence of events includes much dialogue between the various people on the bridge, the AB to the third and second mate and those people to the captain, and also some conversation between the captain and the mate, not all of which I have chosen to include. Also there are numerous hurricane alerts from various organisations, but I have only reproduced a few of them. It is maybe sufficient to say that the forecasts, when they appear, usually show the track of the hurricane moving towards a point where its centre is going to coincide with the course of the El Faro. The sequence of events is summarised from the narrative contained in the NTSB report.

This is the bridge of the ship, where the deck officers were situated when the following recordings were made.

September 28 2015.

1230.The ship arrives at Jacksonville from the previous voyage to Puerto Rico.

1300.Discharge of containers and wheeled vehicles from Puerto Rico commences.

2100.Discharge of the ship ceases for the night.

2236. The national hurricane Centre issues a hurricane warning, that tropical storm Joaquin exists about 400 miles NE of the Bahamas.

September 29 2015

0800. Cargo work resumes.

1003.A second mate on leave texts the captain “storm forming north of Bahamas”.

1651.National Hurricane Centre announces that Joaquin could be a hurricane on the next day.

1831.The off-duty second mate sends another text to the captain saying “what’s your plan?’. The captain replies that he will steam the normal direct route, saying that the storm will remain north of them. The second mate responds with some words about possible alternative routes.

1930. Loading of the cargo for Puerto Rico has been completed.

2007.The vessel casts off, with a pilot on board.

2144.The pilot leaves and the El Faro sets course directly towards Puerto Rico.

2254.The Bahamian government issues a hurricane warning.

September 30 2015.

0443. Further hurricane warnings are issued for the Bahamas, and hurricane hunter aircraft are sent out to investigate Joaquin.

0601.The captain and the chief mate discuss the hurricane referencing the ship’s weather “Bon Voyage System”. The system sends files every six hours to the captain’s computer, requiring him to send them on to the bridge. 

0612. The captain sends a BVS file to the bridge.

0624.Course altered from 133 deg to 140 deg. 

0625.The Sat–C system receives a warning that Joaquin will be 50 nm NE of San Salvador Island with wind speeds of 75 knots gusting to 90 knots. Seas to 27 ft.

0635 to 0719.On the bridge the captain and the mate discuss the weather, the hurricane and the action they are likely to take, deciding not to do much.

1719.The captain asks the mate about the lashing on the cargo. The mate suggesting the longshoremen in Jacksonville “are doing it wrong.”

0739.The National Hurricane Centre issues an advisory. The expected position of the hurricane is 400 nm SE of the El Faro.

0952.The captain of the El Yunque emails the El Faro, saying they are NW of the hurricane and that it is tracking SW. 

1017. The second mate emails her mother, ‘We are heading straight into a hurricane’.

1053.The National Hurricane Centre reports that Joaquin is strengthening and moving SW. 

1108.The captain of the El Faro emails the captain of El Yunque saying that he considers that the closest approach of the hurricane will be 65 nm to the north of the ship. They are making 20 knots.

1147.The transcript has the second mate saying that he (the captain) is saying its not going to be bad, because he realises he’s taken a wrong course (To use the Old Bahama Channel the ship would have had to deviate to the south more or less on departure from Jacksonville).

1312. The captain emails the TOTE DPA (Designated Person Ashore) with a fairly lengthy content mostly confirming that the ship is likely to avoid the hurricane, but that maybe they should use the Old Bahama Channel homeward bound.

1520. The second mate and the AB on watch converse, and conclude that they are heading into the hurricane. Slightly later the AB suggests to captain that they are heading into the hurricane. Once more the captain says that they are going to be 70 nm to the south of it.

1546.TOTE authorise the use of the Old Bahama Channel on the way home.

1547. The second mate reports to the mate that the crew have tightened up the lashings on the vehicles.

1600+ Maybe at the time of change of watch there is an exchange of views on the bridge, during which the captain tells the mate that as a courtesy he had told the company that they will probably return by the Old Bahama Channel. (Obviously the company did not see it that way since they gave permission, rather than acknowledging the information). The AB asks whether they can turn round.

1704. The second mate observes that the ship is going to go right through the eye of the hurricane.

1824. The ship receives a forecast from “The Ocean Prediction Centre” that seas of between 12 and 27 ft can be expected within 90 nm of the storm centre.

1830. The centre of the hurricane is 180 nm SE of the El Faro.

1900.The course is altered again to 150 deg and the captain and the mate discuss the various means by which they can avoid the hurricane, by going SW through one of the several channels between the islands, but actually do very little. 

1957. The National Hurricane Centre announces that an aircraft has found the winds at Joaquin are about 90 knots gusting higher. The hurricane is moving SW at 6 knots. The ship does not receive this information.

2249. The National Hurricane Centre announces that Joaquin had become a category 3 hurricane with wind speeds of 100 knots. This not received by the ship.

2305. The third mate calls the captain to suggest that he might wish to look at the latest forecast, wind speed 100 knots, centre moving SW at 5 knots. He suggests that they will meet the eye of the hurricane at 0400, but he will call back with better numbers. 

2313. The third mate calls the captain again and suggests diverting to the south. He says, ‘At 0400 we’ll be 22 nm from the centre with gusts to 120 and strengthening.’

2326. The third  mate says to the AB,  ‘He seems to think we’ll be south of it by then…’. The AB says he has his survival suit and lifejacket laid out.

2351.The watch is changing. The third mate and the second mate discuss weather and alternative courses including the Old Bahama Channel.

October 1 2015.

0026. The El Faro Sat-C terminal receives an urgent high seas forecast suggesting sustained winds of 100 knots gusting to 120 knots.

0053. There are few records of the actual wind speed at the ship in the report, but the second mate observes that, “when you go outside there is hardly any wind”.

0118. There is a discussion on the bridge about why the ship is rolling.

0120.The second mate calls the captain, apparently suggesting that they alter course to the south through one of the available channels. The captain tells her to continue on the course of 116 deg.

0124.The course is changed to 116 deg, and the ship begins to experience wind heel, and is still making 20 knots.

0131.The National Hurricane Centre issued an advisory which places the hurricane 17 nm ahead of the El Faro, fine on the port bow. The ships does not receive it.

0156.The second mate and the AB remark on the ship’s movements and the loss of speed. It is now travelling at 17.7 knots.

0248. The second mate and the AB react to the increasingly adverse conditions. They say it is becoming difficult to stand on the bridge.

0253. The off-course alarm has sounded for the first time.

0324.The off-course alarm has gone off again and the second mate remarks that the wind speed is increasing and that they are going to “start getting it on the starboard side”. 

0331. Despite the remarks that the anemometer is broken, the VDR records a wind speed of 58 knots. The second mate changes course to 110 deg. Apparently to counteract the set – so it seems that the wind is on the port bow (does this make the centre of the hurricane fine on the starboard bow?). The speed is now 16.8 knots.

0345. Change of watch. The mate arrives on the bridge and alters course firstly to 110 deg and then to 095 deg. The ship is heeling to starboard and the speed is 13.8 knots. 

0412. The captain is now on the bridge. The mate tells him that the off-course alarm has been turned off. The captain suggests maybe filling the port side ramp tank to counteract the wind heel, but the mate says it is not too bad.

0427. With the speed at 8.5 knots the captain asks if they can go any faster, and the speed increases slightly after the engineers have completed blowing tubes.

0446. The chief engineer has asked for the heel to be reduced due to problems with the “list and oil levels”. The ship is put into hand steering and the course is altered to 060 deg. The ship’s speed drops to 7.5 knots.

0447. The El Faro Sat-C system receives an advisory from the National Hurricane Centre identifying the position of the storm centre with wind speeds of 105 knots gusting to 130 knots. The ship is 11 nm NW of the storm centre. 

0514. The captain orders the course “more to the north”. The mate possibly describes the list as 18 degrees, and the speed is now 5.8 knots.

0521. The VDR records a wind speed of 108 knots. 

0543. The speed is now 4.3 knots. The captain receives a call that there is a problem in No 3 hold. He says he will send the mate down and later says “we got cars loose”.

0547. It now seems that the ship is listing to starboard at about 18 deg. The speed has dropped to 2.8 knots. The mate has left to check No 3 hold. The chief engineer is transferring water from the starboard to the port ramp tank.

0559. By now there have been a number of communications between the captain on the bridge and the mate down at No 3 hold. The captain has altered course from 060 deg to 350 deg. And as a result the list has changed from starboard to port. The pumping of water from one ramp tank to the other has now been reversed. The mate and the riding crew supervisor have secured the scuttle to No 3 hold which might have been the source of water ingress.

0613. The ship’s speed is 0.5 knots. The captain says “I think we just lost the plant.”

0644. The captain think he has propulsion available again. The ship is heading NW but travelling SW at a speed over the ground at 6.7 knots.

0648. During an exchange about coffee (!), the captain says they have not got propulsion back after all. 

0657. The captain calls the DPA and leaves a message describing the existing status of the ship, but saying everybody is safe.

0706. The captain is connected with the DPA and describes the ship’s status. A 10 to 15 deg port list and the ferocious conditions, but that their safest bet is to stay with the ship.

0713. A distress message is sent and received by Inmarsat’s earth station at Eik, Norway. They forward the message to the Coast Guard at Portsmouth ,Virginia.

0717. By now it has been determined that the water in No 3 hold is rising, possibly, they think, due to broken pipework relating to the emergency fire pump; the bilge alarm in No 2A hold has sounded.

0728. The general alarm has been rung and the mate has given a command by radio for the crew to muster on the starboard side.

0731. The captain has ordered abandon ship  and says “bow down, bow down”,  and orders the liferafts thrown over and for the crew to enter them.

0739. The recording ends, preceded by exchanges between the captain and the AB on the bridge, the former encouraging the latter as they try to survive. At the time the ship is 17 nm from the hurricane centre.

THE INVESTIGATIONS.

I have read through the reports by the NTSB and the Coast Guard and include here, in my own words, what I regard as the most salient points. The NTSB spends a lot of time telling us about standard marine processes, rules, regulations and guidance, which it just a bit frustrating, while the USCG expects us to already know much of them.

The NTSB report summarises the technique used for loading and assessing the stability of the vessel, and the fact that the mate had been given a pen drive with the information on it. On the fateful voyage the cargo was listed as 238 reefer containers, 118 trailers, 149 autos, 15 “no-in-container’ cargo, 391 containers, 4 fructose tanks (in No 1 and 2 lower holds). During the loading the ship took a starboard list and was photographed in that position leaning against the quay. During previous voyages the ship had also taken a list during loading and on one occasion the captain had stopped the work so that it could be corrected. In this case additional cargo was loaded on the port side to correct the list. The NTSB report suggests that while the GM of the ship seemed to be adequate, as a criterion GM can be applied only to small angles of heel, and we know that as conditions worsened the angle increased to an unacceptable degree, with a corresponding reduction in the righting arm. The stability report goes on to say “it is apparent that the vessel would have been in a vulnerable state and susceptible to capsizing even with flooding only of hold 3, when considering the combined effects of partial flooding, wind heel and roll motion.”

The cargo was lashed in accordance with the Cargo Securing Manual, although the mate had doubts about it, and the crew seemed to have agreed that they should have asked for extra lashings. The NTSB required a review of the cargo lashings to be carried out by the “National Cargo Bureau” and this task was carried out, the results and the modelling reported at some length in the report, but the conclusions were that no containers would have broken free, but probably some trailers would have broken free and the lashing of some cars, particularly if not attached directly to securing points on the deck, would have failed. Of course we know that they did fail.

The NTSB went to considerable lengths to determine what support was provided for the El Faro by the TOTE management during the hurricane, and if it comes to that other hurricanes, and found that no support was available, nor was the progress of the ship’s voyages followed or status of any adverse weather assessed. This approach contrasted with that taken by a number of other companies whose manuals addressed adverse weather and had people to monitor their vessels. In other words despite any expertise provided by the ship’s masters, they offered support. It seems that TOTE were almost unique in not providing the appropriate levels of support. How does that sound? If I was being cynical I would ask how long after the sinking were these very supportive companies interviewed.  

Both the investigations went into the loss of lube oil pressure in some detail and it seemed that the offset of the suction to starboard of the centre line combined with the 18 deg port list  and the lower than recommended oil level would have resulted in a loss of suction, with a resulting loss of the main engine. Of course the rules only expected the ship’s engine to operate at lists of up to 15 deg, and this is a common limit, the expectation being that ships might well roll more than 15 deg but that the time exceeding the limit will be momentary.

Downflooding

The Coast Guard investigation focused finally on the ventilation system of the vessel. The computer model developed a view of the process as the ship gradually lost buoyancy and stability, which might have started off with the open, or partially open scuttle (personnel hatch) into No 3 hold from the second deck on the starboard side. We should bear in mind that the second deck was effectively open to the sea and was awash as the conditions worsened. The captain sent the mate down to have a look and decided to alter course to put the wind on the starboard side so that he could get to the scuttle and close it. But by then the No 3 lower hold was already deep in water and vehicles were on the move. The suggestion that the pipework to the emergency fire pump was  compromised is unlikely, the NTSB investigators thought,  but by the time the captain returned to the bridge at about 4 am, it was probable that the No 3 ventilation system was being partially immersed and was taking in water. 

Things were already looking rough for the ship, when the captain decided to alter course to put the wind on the starboard side, giving it a port wind heel. It seems likely that the list was more than 15 deg, and the various investigations determined that the suction in the lub oil sump would be above the surface of the oil. The engine would then have stopped and so no action would be possible for the ship. When the vessel was beam on to the seas still rolling about a point 15 deg to port, the No 3 ventilation system would have been under water for much of the time, gradually filling up the hold. Later water migrated to No 2A, which might have been through a leaking watertight door between the holds, or else though the ventilation system as well. However the investigators determined that the ship would not have survived the flooding on No 3 hold only. 

The NTSB comment about the inlet and exhaust vents was that neither the inlet or outlet vents would be considered to be downflooding points by the “International Code on Intact Stability” because the exhausts were protected by weathertight dampers, and the inlets by watertight dampers. But they determined that there were no instructions to close these vents – and anyway that they were required to be open to provide ventilation when vehicles were carried in the holds. The NTSB thought that had a requirement to close these vents been identified anywhere, then the ship’s crew might have closed them. Information might have been contained in a “Damage Control Booklet” had one been available, but there is no certainty that the El Faro actually required one.

The Captain’s Decision Making.

In all of this it is difficult to believe that the captain did not come to the bridge when requested to do so by the third mate and then the second mate, but instead just issued instructions that they were to carry on, taking the course that had been drawn on the previous day. It is suggested that he decided to take the risk of passing close to the storm, thinking that it was going to turn NE, and only accepting information that tended to confirm that approach (confirmation bias). It would also be true that if he took any of the alternative routes, starting off with the Old Bahama Channel immediately after departure, the ship would almost certainly have come through totally unscathed, but he would have to justify the alternative route since it was 130 miles longer and he would have arrived late – missing the two hour allowance. This, it is thought, might have influenced the management against his possible appointment to one of the new ships.

I would have wanted to know why an on leave second mate had promoted himself to the role of Marine Superintendent, and even why the captain was so polite to him. What was their previous relationship?

The NTSB also determined that the concept of Bridge Resource Management had not been promoted by the company and that the watch officers had not been sufficiently persuasive in their efforts to get the captain to alter course. Their report says that although they discussed the situation between themselves they did not approach the captain with their concerns. And in their findings they censure the watch officers for this. Actually in their own recording of the VDR conversations, in addition to the second mate’s and the third mate’s calling the captain from the bridge, the AB on watch twice asked the captain what he was going to do, once asking directly whether they could turn round. In this aspect of the report I can’t help thinking that the NTSB were suffering from confirmation bias themselves, ignoring the actual evidence in order to make their point; one of the board in any case dissociated themselves from this finding.

Reviewing what passed between the captain and his support it seems to me that the one person who might have made a difference was the chief mate, who seemed to be going along with the captain as he did nothing. Did he actually agree with the captain, or was he just keeping his head down and hoping for the best?

OTHER FACTORS

There is much about the LSA in the NTSB report, and how things might have been different if the ship had had enclosed boats, and maybe we would be surprised that there are 152 US flag vessels more than 30 years old still sailing, which as a result are provided with open boats. However I have chosen not to report on this failing further, or on the other LSAs; there are already too many words to make this document an easy read.

The NTSB made 50 recommendations addressing many aspects of the failings, in the expectation that ships will operate more safely in the future. 

The Coast Guard made 36 recommendations. Coast Guard investigations are subject to scrutiny by their Commandant, who has the authority to reject recommendations if he does not like them. Unsurprisingly the Marine Board Investigation recommended changes to the regulations concerning ventilation closures, however he said “there is no evidence to support that current closure requirements are insufficient”.  He also “concurs with the intent of other recommendations”, and did not concur with a recommendation that ship’s electronic records should be regularly transmitted to the shore, or that all existing cargo vessels meet the most current intact and damage stability standards.

COMMENT.

It is one of those things that when a ship takes a list it is necessary for those who are involved to try to determine exactly why before doing anything. The ship took a list during the loading of the cargo for the final voyage. Was it sufficient to just correct the problem using cargo? And pumping liquids when there are problems almost inevitably leads to disaster (I have written Emergency Response Manuals, where I have specifically addressed this point). 

One of the witnesses described the decision making problems relating to abandoning ship. The main thrust of such a discussion is that, in general, the crew of a ship is safest staying on it, as long as it remains afloat. So the man in charge must decide exactly when it is no longer safe to remain on board, and this will almost certainly be at a time when it will be difficult to abandon.

A weathertight vent on the El Yunque from the Coast Guard report

Anybody who has ever dealt with those slatted ventilator closures will be able to testify that they are virtually impossible to maintain. After forty years there is not the slightest possibility that they would pass a hose test, the usual way of determining weathertightness, even if you could actually close the things. The fact that no-one closed them is really neither here nor there. The existence of these ineffective components allowed the ventilators to be fitted at a height above the waterline, which is totally inappropriate, that is even if the original loadline had been maintained, and the vent closures were in a good condition. The Coast Guard had, after inspecting these ducts on the El Yunque, inspected many such vent systems on other vessels, and as a result hundreds of fittings had been replaced and ships detained. The El Yunque went to the scrapyard.

TOTE had followed an approach taken by many shipping companies, of disposing of the role of Marine Superintendent and his assistants, taking the view that the marine stuff can be carried out by the shipmasters, and the engine stuff requires the further attention of the shore squad. Hence the captains are just cast adrift with their ships, left alone to get on with it. TOTE had gone as far as to leave out any references to the risks of going to sea, from its Operations Manual, even though they had quite detailed instructions about how to deal with a hurricane in the offices on shore. 

So the NTSB determined that the probable cause of the accident was the captain’s failing to take sufficient  action to avoid the hurricane, and actually it seems very likely that had the ship turned right on leaving Jacksonville and taken  the Old Bahama Channel the ship, and everybody on it would have survived – and all the other failings identified by the investigation would have gone unnoticed. But surely by going back to one of the first questions posed, had the engine kept working the survival of the ship seems more likely, and had the ventilation closures been operated, and been effective and had the scuttle on the starboard side of the second deck accessing No 3 hold been closed, the ship could have remained watertight, therefore reducing the possibility of the vehicles becoming mobile and the free surface in the hold slopping about. So regardless of the captain’s error the survival of the ship seems probable. Really, by 1975, newly constructed ships could be made watertight if operated properly, particularly if the cargo could be prevented from shifting. 

So what could we take away from the investigations? Basically it is the same message that I for one have been promoting for years, and this is regardless of any formal regulatory requirements, which we find time and again are found wanting, or prone to circumvention: 

  1. Take responsibility for the safety of others comensurate with your position in the organisation.
  2. Carry out suitable major hazard risk assessments using informed and expert personnel.
  3. Ensure that everybody is suitably trained and qualified for the positions they hold.
  4. Provide effective guidance for your staff, no matter how expert they may appear to be.
  5. Keep your vessel watertight at all times.

 

 

 

 

 

 

 

 

 

 
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