El Faro: NTSB Releases Human Factors Report

The National Transportation Safety Board released a Human Performance Factual Report earlier this month as part of its investigation into the sinking of the El Faro, citing leadership, training and working hours issues on board.

The El Faro sank near the Bahamas in October 2015 en route from Jacksonville to Puerto Rico during Hurricane Joaquin.

Captain Michael Davidson, similar to the other officers, normally worked a 10-week rotation, having 10 weeks off after working for 10 weeks on the ship. He started a work rotation on May 5, 2015, and left the ship, as scheduled, on July 14. His relief resigned just three weeks later, and the captain was asked to return to El Faro earlier than anticipated. On August 11, four weeks into his vacation, he returned to work on El Faro.

El Faro’s officers had employment contracts with TOTE through AMO. They were expected to work 12 hours a day while on the vessel under their contract. Actual work hours for the accident voyage were not available to investigators. However, during the two-week period from August 24 to September 6, 2015, the average workday was approximately 13 hours for El Faro’s officers. For the next 2-week period leading up to the accident voyage, from September 7 through September 20, the work hours were 12.5 hours.

The report documented several reports of fatigue among the El Faro's crew in the weeks leading up to the sinking. According to testimony, the chief engineer had told his wife that he was exhausted from extra maintenance work, and had described his last rotation as the worst he had been on in terms of maintenance issues. Two friends of the second mate told investigators that she complained about fatigue from her watch schedule and the additional work required at sea. In the hours before the sinking, the El Faro's VDR picked up a conversation in which she told her watch AB that she took ZzzQuil (a sleep aid with the same active ingredient as Benadryl) to help her rest.

The captain’s voyage plan has been widely discussed given the presence of the hurricane. Investigators found no evidence that users of weather forecasting system on El Faro had any formal training with the system. Testimony from deck officers indicated that there was on-the-job training, and a user’s manual and quick reference guide were readily available for use on the vessel.

The company did not issue alerts or email communications about Hurricane Joaquin before or during the fatal voyage. During interviews, TOTE managers repeatedly stressed that the captain could make any and all decisions related to the vessel’s operation. They also stated that the captain would approve the voyage plan unilaterally and make all voyage-related decisions without the concurrence of shoreside management. 

According to shipowner TOTE, the captain was the primary nautical expert: “There is no one in the company that formally provides oversight for nautical. We depend on the captains to take on that role.” However, company emails also indicate that some managers saw the El Faro captain as a “stateroom captain,” with one voicing “dwindling confidence” in him. The captain had been advised around May 12 by the director of labor relations that he was not selected to work on TOTE’s new LNG ships.

The day after the vessel got under way, the captain reported that he had been monitoring Hurricane Joaquin “tracking erratically” for the better part of a week. In an email to shoreside management, he stated that he had previously adjusted his course to a more southeasterly direction to account for Joaquin, and that he anticipated passing approximately 65 nautical miles to the south of the eye of the storm.

The National Transportation Safety Board released a transcript of the bridge audio recording from the El Faro's final voyage in December last year. For the last few minutes of the recording, after the captain had ordered the crew to abandon ship, he attempted to help the helmsman to get out of the bridge; the AB called for a line or a ladder, but neither were at hand. Both men were within range of the bridge microphones until the end.

The NTSB Human Performance Factual Report is available here.