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El Faro investigation prompts NTSB to issue safety recommendations ahead of final report

El Faro investigation prompts NTSB to issue safety recommendations ahead of final report

El Faro investigation prompts NTSB to issue safety recommendations ahead of final report
The eye of Hurricane Joaquin is visible in the lower left corner of this image taken from the International Space Station Oct. 2, 2015

El Faro investigation prompts NTSB to issue safety recommendations ahead of final report

While their larger investigation of the El Faro sinking is still ongoing, the NTSB has issued ten new recommendations as a result of their work so far, to encourage immediate action on mariner safety

“We are getting these recommendations out as the hurricane season begins so that the work on these safety improvements can start immediately,” says a statement from NTSB Acting Chairman Robert L Sumwalt. 

The goal of the recommendations is to improve the accuracy of hurricane and tropical cyclone forecasts and to make them more accessible at sea.

FULL COVERAGE:The sinking of El Faro

Two of the recommendations have been issued to the National Oceanic Atmospheric Administration, seven to the National Weather Service, and one to the US Coast Guard, with the NTSB urging the organizations to adopt them. 

The NTSB acknowledges that, generally, safety recommendations are issued at the end of an investigation, but can be put out at any time.

NTSB INVESTIGATION: Details from the NTSB’s Investigative Reports

The Board has been investigating the sinking of El Faro since late 2015, which included participating in three Coast Guard Marine Board of Investigation public hearing sessions as well as producing the longest transcript of a Voyage Data Recorder- or “black box”- that the NTSB has ever completed. 

33 people died when the cargo ship out of Jacksonville sank in Hurricane Joaquin in October 2015. During his final shoreside communication, El Faro’s Captain reported the ship had lost propulsion and taken on water, resulting in a fifteen degree list.

AUDIO: El Faro’s Captain reports “marine emergency”

The VDR transcript- which included conversations from the bridge- showed the engineers were struggling to get things running again and containers were coming loose.

FULL DETAILS: El Faro’s VDR captures final moments ahead of El Faro’s sinking

The investigation so far has raised questions about how the cargo was secured and the condition of the ship in the area that water came on board. We’ve also learned the vessel had some outdated weather information in the hours ahead of the sinking, didn’t receive all communications, and that the forecasting errors on Hurricane Joaquin itself were more significant than normal.  

The end of the VDR did capture the Captain calling to abandon ship, but none of the crew were ever recovered. 

GALLERY: Tributes to the El Faro crew

The NTSB expects to complete their investigation of the sinking later this year, which will include a finding of probable cause and contributing factors to the sinking. The Coast Guard Marine Board of Investigation will also issue its own separate report. 

Recommendations to NOAA

The NTSB Safety Recommendation Report discusses the challenges in forecasting Hurricane Joaquin, with the National Hurricane Center reporting it as one of the most challenging storms for forecast track. Part of the problem, according to testimony during the MBI, was the shear environment- which was moderate. One of the recommendations is to develop and implement a plan to improve forecasting track and intensity in such a moderate-shear environment. The NTSB report says there was a NOAA program which included this goal, but they have recently moved away from this type of research.

A second recommendation is to develop and implement technology to help National Weather Service forecasters quickly sort through data and forecast models to try to detect clusters of information that could help determine the best guidance.

“NHC staff told the NTSB that this capability could have made a difference in the forecasting for Joaquin,” the NTSB report says.

Recommendations to NWS

One of the weather systems mariners use to get weather information is called Inmarsat-C SafetyNET (SAT-C), which is a text broadcast of NHC weather products that goes to the ship’s bridge. During a tropical cyclone, an advisory is issued through this system four times a day. An Intermediate Public Advisory is also issued every three hours by the NHC once watches and warnings for tropical storms or hurricanes are issued, but these intermediate advisories are not available through SAT-C. The first NTSB recommendation in this area involves developing and implementing a plan to make the intermediate advisories available through this system. The report says there was an Intermediate Advisory issued on Joaquin just a few minutes after the crew communicated with the Captain about their course in the hours ahead of the sinking, but El Faro did not get that advisory through that system, because it’s not required.

“The advisory would have identified to the crew that El Faro’s current course was taking them almost directly toward the center of the southwest-moving hurricane,” the report says.

Another recommendation would require the Intermediate Advisory be issued even if the tropical storm or hurricane is not a threat to land- which is the focus under the current advisory construct. This would give new information to mariners in the open water.

Some of the recommendations deal with trying to prevent any potential for confusion dealing with the timing of the advisory. The NTSB is calling on the NWS to take steps to make more clear when subsequent advisories will be issued. Additionally, the NTSB recommends defining a “significant change” in a storm for both track and intensity, to better streamline when new “Special Advisory packages” will be issued for a storm. Those Special Advisories are issued now if there is a watch or warning issued between regular advisories, or if there is an “unexpected significant change” in the storm- which is currently defined by informal protocol.

“Despite Joaquin’s repeated tendency during the days before El Faro sank to move south of its short-term forecast track, as well as two periods of stronger-than-expected short-term intensification, the only Special Advisory package for Joaquin was issued at 1200 EDT on October 3, 2015. That was 2 days after the sinking, when the NHC adjusted Joaquin’s initial and forecast intensity,” the NTSB report says.

Another system a ship can use to get weather information is called FTPmail. Users can send a request and receive large data packets of real-time NWS text and graphics through standard email, but the system is not automated. One recommendation is to allow users to scheduling recurring deliveries, and another is to include more graphics products.

The final recommendation for NWS is to develop a plan for soliciting feedback from mariners about the accuracy, timeliness, and usability of the weather products. The NTSB says there hasn’t been any such solicitation since 2007.

Recommendation to the Coast Guard

While the NTSB sees the Coast Guard as a partner in the implementation of some of the above recommendations, the only direct recommendation to USCG deals with their broadcast of NWS data.

This broadcast goes out through various outlets. The NTSB wants to see the Coast Guard and NWS more closely collaborating on what information is being distributed through this means, to include Intermediate Advisories, Tropical Cyclone Forecasts, and more. The NTSB acknowledged this may not be easy to achieve, because of the constraints around the allocation of the broadcast window, but says it could be an important way for mariners to get timely and comprehensive information.

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