Coast Guard Releases Final Report on El Faro Tragedy


By The Maritime Executive 2017-10-04 19:13:39

The Coast Guard Marine Board of Investigation (MBI) has released its final report into the sinking of the con/ro El Faro on October 1, 2015. The 200-page document outlines the timeline of the vessel's final voyage, outlines the causal factors behind her loss and gives recommendations for preventing future casualties.

In a statement before the report’s release, Captain Jason Neubauer, the chairman of the MBI, emphasized the investigation’s ultimate purpose. “The most important thing to remember is that 33 people lost their lives in this tragedy. If adopted, we believe the safety recommendations in our report will improve safety of life at sea,” he said. 

The Board's conclusions draw on the extensive evidence presented in factual reports, audio transcripts, hearing testimony and other documents that have already been published. The Board found that the El Faro's operator, TOTE, did not ensure the safety of marine operations for the vessel and did not identify the risks posed by Hurricane Joaquin before her final voyage. The MBI also found that the El Faro's master was partly responsible for the tragedy, and alleged that he "failed to carry out his responsibilities and duties as Captain of the vessel.”

The report also addresses broader concerns of compliance and maintenance standards. Based on the inspection records of the El Faro and her sister ship, the El Yunque, the Board expanded the scope of its inquiry to cover the Alternate Compliance Program (ACP), under which six class societies are authorized to inspect commercial vessels on behalf of the Coast Guard. The Board found a pattern of deficiencies among a subset of ACP vessels, and it asserted that a “seminal change in the overall management and execution of the [ACP] is urgently needed to ensure safe conditions are sustained on the enrolled U.S. commercial vessels.” The board’s findings on the ACP can be found at the end of this article.  

The National Transportation Safety Board (NTSB) is conducting its own, parallel review of the El Faro tragedy in cooperation with the Coast Guard. NTSB plans to meet on December 12 to vote on its conclusions. 

The MBI report’s executive summary, conclusions and recommendations are presented below, along with selected illustrations. The full document may be found at this link


Marine Board's Report: Sinking and Loss of the Steam Ship El Faro with 33 Persons Missing and Presumed Deceased

1. Executive Summary

The loss of the U.S. flagged cargo vessel EL FARO, along with its 33 member crew, ranks as one of the worst maritime disasters in U.S. history, and resulted in the highest death toll from a U.S. commercial vessel sinking in almost 40 years. At the time of the sinking, EL FARO was on a U.S. domestic voyage with a full load of containers and roll-on roll-off cargo bound from Jacksonville, Florida to San Juan, Puerto Rico. As EL FARO departed port on September 29, 2015, a tropical weather system that had formed east of the Bahamas Islands was rapidly intensifying in strength. The storm system evolved into Hurricane Joaquin and defied weather forecasts and standard Atlantic Basin hurricane tracking by traveling southwest. As various weather updates were received onboard EL FARO, the Master directed the ship southward of the direct course to San Juan, which was the normal route.

The Master’s southern deviation ultimately steered EL FARO almost directly towards the strengthening hurricane. As EL FARO began to encounter heavy seas and winds associated with the outer bands of Hurricane Joaquin, the vessel sustained a prolonged starboard list and began intermittently taking water into the interior of the ship. Shortly after 5:30 AM on the morning of October 1, 2015, flooding was identified in one of the vessel's large cargo holds. At the same time, EL FARO engineers were struggling to maintain propulsion as the list and motion of the vessel increased. After making a turn to shift the vessel’s list to port, in order to close an open scuttle, EL FARO lost propulsion and began drifting beam to the hurricane force winds and seas.

Illustration of significant events between 4:20 AM on October 1 and the sinking, showing ship heading and course over ground (MBI)

At approximately 7:00 AM, without propulsion and with uncontrolled flooding, the Master notified his company and signaled distress using EL FARO's satellite distress communication system. Shortly after signaling distress, the Master ordered abandon ship. The vessel, at the time, was near the eye of Hurricane Joaquin, which had strengthened to a Category 3 storm. Rescue assets began search operations, and included a U.S. Air National Guard hurricane tracking aircraft overflight of the vessel’s last known position. After hurricane conditions subsided, the Coast Guard commenced additional search operations, with assistance from commercial assets contracted by the vessel’s owner. The search located EL FARO debris and one deceased crewmember. No survivors were located during these search and rescue operations.

On October 31, 2015, a U.S. Navy surface asset contracted by the NTSB, using side-scan sonar, located the main wreckage of EL FARO at a depth of over 15,000 feet. EL FARO's voyage data recorder was successfully recovered from EL FARO’s debris field on August 15, 2016, and it contained 26-hours of bridge audio recordings as well as other critical navigation data that were used by the MBI to help determine the circumstances leading up to this tragic incident.

Recovering El Faro’s VDR (USN)


Events and Contributing Factors

9.1.1. Event #1: EL FARO Sailed Within Close Proximity to Hurricane Joaquin TOTE did not ensure the safety of marine operations and failed to provide shore side nautical operations supports to its vessels. TOTE did not identify heavy weather as a risk in the Safety Management System (SMS) and the Coast Guard had not exercised its flag state authority to require identification of specific risks. TOTE and the Master did not adequately identify the risk of heavy weather when preparing, evaluating, and approving the voyage plan prior to departure on the accident voyage. TOTE and the Master and ship’s officers were not aware of vessel vulnerabilities and operating limitations in heavy weather conditions. TOTE did not provide the tools and protocols for accurate weather observations. The Master and navigation crew did not adequately or accurately assess and report observed weather conditions. TOTE did not provide adequate support and oversight to the crew of EL FARO during the accident voyage. The National Hurricane Center (NHC) created and distributed tropical weather forecasts for Tropical Storm and Hurricane Joaquin, which in later analysis proved to be inaccurate. Applied Weather Technologies used these inaccurate forecasts to create the Bon Voyage System (BVS) weather packages. The Master and deck officers were not aware of the inherent latency in the BVS data when compared to the NHC forecasts. Additionally, the Master and deck officers were not aware that they received one BVS data package with a redundant hurricane trackline. The Master and deck officers relied primarily on graphical BVS weather forecasts rather than the most current NHC data received via SAT-C. EL FARO crew did not take advantage of BVS’s tropical update feature and the ability to send BVS weather information directly to the bridge. The Master did not effectively integrate the use of Bridge Resource Management techniques during the accident voyage. Furthermore, the Master of EL FARO did not order a reduction in the speed or consider the limitations of the engineering plant as EL FARO converged on a rapidly intensifying hurricane. This resulted in loss of propulsion, cargo shifting and flooding. The Master of EL FARO failed to carry out his responsibilities and duties as Captain of the vessel between 8:00 PM on September 30 and 4:00 AM on October 1, 2015. Notably, the Master failed to download the 11:00 PM BVS data package, and failed to act on reports from the 3/M and 2/M regarding the increased severity and narrowing of the closest point of approach to Hurricane Joaquin, and the suggested course changes to the south to increase their distance from the hurricane. The cumulative effects of anxiety, fatigue, and vessel motion from heavy weather degraded the crew’s decision making and physical performance of duties during the accident voyage.


9.1.2 Event #2: EL FARO Experienced an Initial Starboard List and Intermittent Flooding EL FARO developed a sustained wind heel to starboard as a result of the course change from 155 degrees to 116 degrees after passing south of San Salvador at approximately 1:30 AM on October 1. The wind heel brought the 2nd deck closer to the water line. Intermittent flooding into one or more cargo holds on EL FARO began at this time. Water was able to enter Hold 3 through the open scuttle, and likely through deteriorated internal structures and open cargo hold ventilation fire dampers, which compromised watertight integrity. The increasing of EL FARO’s load line drafts following the 2005-2006 conversion, combined with loading to near full capacity with minimal stability margin, increased the vessel’s vulnerability to flooding in heavy weather. Despite the apparent increase in cargo carrying capacity and increase load line draft which would result, the 2005-2006 conversion was not designated as a major conversion by the Coast Guard. Based on the available documentation, the final decision was based on the “Precedence Principle,” in that the Coast Guard had previously not designated similar conversions of sister vessels EL YUNQUE and EL MORRO as major conversions. The crew’s complacency, lack of training and procedures, and EL FARO’s design contributed to the crew’s failure to assess whether the vessel’s watertight integrity was compromised. EL FARO’s conversion in 2005-2006, which converted outboard ballast tanks to fixed ballast, severely limited the vessel’s ability to improve stability at sea in the event of heavy weather or flooding. The Master, C/M, and crew did not ensure that stevedores and longshoremen secured cargo in accordance with the Cargo Securing Manual, which contributed to RO/RO cargo breaking free. The practice of sailing with open cargo hold ventilation system fire dampers in accordance with SOLAS II-2, Regulation 20 and U.S. regulations created a downflooding vulnerability which is not adequately considered for the purposes of intact and damage stability, nor for the definitions of weathertight and watertight closures for the purpose of the applicable Load Line Convention. The Coast Guard practice of verbally passing deficiency information to the ACS surveyor without written documentation of the deficient condition resulted in an unknown or incomplete compliance and material condition history of EL FARO.


9.1.3 Event #3: EL FARO experienced a reduction in propulsion EL FARO’s reduction in speed, from approximately 16 knots to 9 knots that occurred between 3:45 AM to 4:15 AM on October 1 was the result of the routine blowing of tubes and the C/M making course changes. EL FARO never reached a speed through the water above 10 knots for the remainder of the voyage. EL FARO’s departure with a main lube oil sump level of 24.6”, which was below the Machinery Operating Manual recommended operating level of 27”, reduced the crew’s ability to maintain lube oil suction for the main propulsion plant. Prior to 4:36 AM, EL FARO’s main propulsion unit developed intermittent lube oil problems due to the starboard list.


9.1.4. Event #4: EL FARO Incurred a Severe Port List and Lost Propulsion At 5:54 AM on October 1, the Master altered course to intentionally put the wind on vessel’s starboard side to induce a port list and enable the C/M to access and close the Hold 3 starboard scuttle. This port list was exacerbated by his previous order to transfer ramp tank ballast to port, and resulted in a port list that was greater than the previous starboard list and a dynamic shifting of cargo and flood water. The port list, combined with the offset of the lube oil suction bellmouth 22” to starboard of centerline, resulted in the loss of lube oil suction and subsequent loss of propulsion at around 6:00 AM. Coast Guard and ABS plan review for EL FARO’s lube oil system did not consider the worst case angle of inclination in combination with the full range of lube oil sump operating levels specified in the machinery operating manual. This led the crew to operate with a lube oil sump level within the operating range specified on the Coast Guard and ABS approved drawing, but below the 27” operating level, which was the only level reviewed by ABS. The Master and C/E did not have a complete understanding of the vulnerabilities of the lube oil system design, specifically the offset suction. This lack of understanding hampered their ability to properly operate the ship in the prevailing conditions. TOTE’s lack of procedures for storm avoidance and vessel specific heavy weather plans containing engineering operating procedures for heavy weather contributed to the loss of propulsion.

USCG static simulation


9.1.5. Event #5: EL FARO sank The loss of propulsion resulted in the vessel drifting and aligning with the trough of the sea, exposing the beam of the vessel to the full force of the sea and wind. Even after securing the scuttle to Hold 3, water continued to flood into cargo holds through ventilation openings, and also likely between cargo holds through leaking gaskets on large watertight cargo hold doors. The EL FARO crew did not have adequate knowledge of the ship or ship’s systems to identify the sources of the flooding, nor did they have equipment or training to properly respond to the flooding. Even though EL FARO met applicable intact and damage stability standards as loaded for the accident voyage, the vessel could not have survived uncontrolled flooding of even a single cargo hold given the extreme wind and sea conditions encountered in Hurricane Joaquin.


9.1.6. Event #6: All 33 Persons Aboard EL FARO Are Missing and Presumed Deceased A lack of effective training and drills by crew members, and inadequate oversight by TOTE, Coast Guard and ABS, resulted in the crew and riding crew members being unprepared to undertake the proper actions required for surviving in an abandon ship scenario. After 5:43 AM on October 1, the Master failed to recognize the magnitude of the threat...

The opinions expressed herein are the author's and not necessarily those of The Maritime Executive.