"We all owe it to the El Faro 33 to learn what happened"

33 black ribbons- one for each of the lives lost with the sinking of El Faro.

It’s been sixteen months since the ship went down in Hurricane Joaquin, while transiting from Jacksonville to Puerto Rico. All 33 on board are presumed dead, although only one body was located, and none were recovered.

A plaque not sits on the ship’s wreckage on the ocean floor to honor the lives lost, but for many families, the best tribute would be answers and change.

GALLERY: Tributes to El Faro's crew

Friday marked the end of the third and final two-week hearing session of the Coast Guard Marine Board of Investigation. 22 witnesses testified during this phase, several of who had given prior testimony, but were called back to add more information and context, especially with the recovery of the ship's Voyage Data Recorder.

It took three separate missions led by the NTSB to locate and ultimately recover the VDR, or black box. The NTSB invited the MBI and a few select others- including some from El Faro's owner and operator- to listen and help with their transcription. We're told the transcript is the longest ever assembled by the NTSB, although the audio itself will not be released. Conversations from the black box were frequently referenced through this final hearing session, raising questions about the safety culture, voyage planning, engine room problems, and the sequence of flooding.

“It’s going to help us really tighten up on some of the facts that we would have had to speculate on, certainly if we hadn’t had it. And it also helped us pursue several leads that we wanted to, since we had the VDR and the transcript in hand, that we could follow on this session,” says MBI Chair Captain Jason Neubauer.

From listening to the VDR himself, Neubauer says his resolve as an investigator was strengthened.

"The crew tried as hard as they could, and there were definitely heroic actions to try to save other members and the ship itself," he says.

While the NTSB participated in the MBI public hearing sessions in order to avoid duplicating some key parts of the investigation, they’re conducting their own investigation and will issue findings independent from the Board.

FULL COVERAGE: NTSB Factual Reports on the El Faro sinking

Five witnesses who were on the schedule for this hearing session were ultimately removed, because of time constraints. We’re told the Board selected which witnesses to remove based on the information they anticipated getting from that witness, and their ability to get similar information from someone else who may also be able to speak to other topics. For those witnesses, the MBI is now limited to only written documentation, like emails, which they’ve uncovered through their investigation, but Neubauer says he’s confident the witnesses they called have given the information they needed.

The NTSB has conducted separate interviews with a range of witnesses and interested parties, and while transcripts of those interviews have been made public, the MBI will not be using them because the "Parties in Interest" in their investigation weren't able to be involved in the NTSB questioning.  TOTE Inc, the American Bureau of Shipping, Herbert Engineering, and the widow of El Faro Captain Michael Davidson were all named PII's to the MBI, meaning the Board believed they would be able to provide valuable information to their work. It also meant those parties were able to question witnesses through the hearing sessions.

FULL COVERAGE: El Faro sinking

Families of the fallen crew are anxiously awaiting the end result of this exhaustive process, hoping that there is real industry change that comes as a result.

One of the crew families wanted to honor the crew through placing a plaque on the wreckage. With the support of many of the other families involved, a plaque was commissioned, and the plaque was able to be dropped on to the wreckage during the voyage to recover the VDR.

“This plaque was placed on this site August 2016 to honor the crew of the El Faro who were lost at sea during Hurricane Joaquin October 1, 2015,” the plaque reads.

The family involved emphasized that the plaque would not have been placed if it had at all compromised the VDR recovery, also stressing that it is to honor the crew, not to mourn or memorialize them.

Through the hearing sessions, some of the crew families have paid tribute in other ways. During the second session, one family member brought in a hand-painted anchor that had all 33 names on it, sitting the anchor in the front row. She made them for all of the families.

Others have donned tribute shirts, which include a prayer on the back and the inscription "Lost But Not Forgotten". One family set up a foundation to help others enduring a tragedy, while another is working to organize and initiate industry change.

Through this final session, photos of some of the fallen crew have sat in the front row of the hearing room. The line of photos included a special dedication to the five members of the Polish riding crew who were on board, as well as a helmet of one of the crew members, which had washed ashore in Ormond Beach.

GALLERY: Crew families pay tribute through third MBI session

On the final day, instead of a row of photos, two and a half rows sat with black ribbons. Another black ribbon wrapped around the edge of the seating section, and front row center sat a bouquet of flowers and a plaque that says "In Loving Memory Of Those Forever In Our Hearts".

Neubauer says seeing the emotional toll of the sinking is a driver for their work. He also credits the families and public for giving them information that helped branch out their investigation.

“It definitely led us to new witnesses and information that we probably would not have obtained if we hadn’t tried to put the reach out to get that information,” he says.

At the conclusion of the testimony, all of the involved parties were given the opportunity to make a statement. WOKV has transcribed those statements, so you can read them in full below.

After his closing statement, Neubauer called for a 33 second moment of silence to honor the lives lost in the sinking. As the room rose and bowed their heads, the names of the mariners who were on board were projected on to a screen. Once the session concluded, the families gathered in prayer.

VIDEO: El Faro crew families gather in prayer

It’s unclear at this time how long it will take either the MBI or the NTSB to issue their separate findings.

“It’s going to take as long as it takes to get it right,” Neubauer says.

The MBI will issue its report to the Commandant of the Coast Guard, who will ultimately issue the final findings. Neubauer says his chain of command and the Commandant have been closely following their work.

He couldn't speak to specifics at this point, but says there are clearly multiple factors that contributed to what happened.

“I definitely see recommendations coming as the result of this investigation, the process now is just to identify exactly what we need to do,” he says.

In fact, he says there have already been industry changes. ABS confirms they have been continually working on improvements to the Alternate Compliance Program- the inspection program over El Faro and other commercial vessels. Neubauer says the Coast Guard has also been working on improvements on their end of the program. He also believes others in the maritime industry have been closely watching these proceedings, and continually looking for opportunities for change, even before the final reports are issued.

Closing statements

William Bennett, who represented Theresa Davidson- the wife of El Faro Captain Michael Davidson- read a statement on her behalf.

“I offer my condolences to the families of the crew members on the El Faro, which was lost on Oct 1, 2015. My daughters and I know the pain you feel, as do Michael’s siblings and parents. I want to thank the Coast Guard and the NTSB for their hard work and their dedication in investigating the circumstances surrounding the loss of the El Faro. I also want to thank the ABS, Herbert Engineering, and TOTE for cooperating with the investigation. It gives me comfort that those charged with conducting this investigation will continue to work to identify errors for future improvement in order to strengthen the safety of those who spend their lives at sea. This investigation has uncovered many facts that were unknown before the Board was established. One of the most significant facts we learned was the National Hurricane Center’s forecast of Hurricane Joaquin was one of the worst in history and weather data sent to the vessel was inaccurate. Through the course of this investigation, you learned a little bit about who Michael was as a ship’s Captain. Crew members- both licensed and unlicensed- who sailed with Michael described him as meticulous, concerned for safety, caring for the welfare of his crew, and a true professional. But Michael was much more than a ship’s Captain. He was a son, an older brother, a terrific father of two daughters, and an amazing husband. And if you really want to know who Michael was at his core, you only need  to read the last pages of the VDR. He willingly gave up the opportunity to fight for his own survival because he refused to leave a crew member behind. Some were surprised that Michael made that choice, I was not. Sincerely Theresa Davidson.”

Bennett then added his own statement.

“On a personal note, to the family members for their kind words to me- the dignity and grace that you’ve shown is absolutely heartwarming, and I will carry it with me for the rest of my life. And for Theresa, who is listening on the phone, it’s been an honor to represent your husband here, thank you.”

On behalf of TOTE, who’s companies owned and operated El Faro, TOTE Maritime Puerto Rico President Tim Nolan addressed the room.

“On Oct 1, 2015, we unfortunately lost the El Faro and her crew. 33 families were directly impacted, the TOTE organization, and the whole maritime industry. I would like to again extend our sincere and heartfelt condolences to each one of the families and their loved ones of the El Faro crew. We will never truly know the pain and loss that you have gone through. I do know how deep it has impacted our organization and the maritime industry. Please know your families will forever be in our memories. Their names are immortalized on the walls at the AMO and the SIU, as well as at their respective academies, and on the monument at the El Faro Memorial Park. They’ll forever be in our heart, and they’ll never be forgotten. Over the past 16 months I’ve gotten to know many of you. We’ve shared some hugs, we’ve shared some laughs, we’ve shared some tears, and we’ve even shared a few meals. One thing I can say- I’m amazed at your strength and your courage. You’ve truly served as an inspiration to me, and I can say to the TOTE organization as well. I would like to thank Captain Neubauer and the US Coast Guard, Mr. Young and the NTSB, and everyone else who’s been involved in the Marine Board of Investigation. I know you’ve invested countless hours in to this process to truly understand what happened and to provide answers to the families, to TOTE, and to the rest of the industry. We all owe it to the El Faro 33 to learn what happened and to share these learnings with the maritime community. We are aware this is one of the largest Marine Boards in relation to the loss of a vessel and a crew, and for that, we truly thank you. Your efforts and commitments are what I would say are miraculous. You located the El Faro, you located its VDR, and you retrieved the VDR. I don’t know if a VDR has ever been retrieved at such depths before. And not only did you retrieve the VDR, but you extracted valuable data from the VDR that confirmed what many of us already knew. We knew that it was a truly brave crew and experienced crew and one that was there to help one another. And they fought for the safety of the vessel until the end. They will forever be true heroes. We look forward to your completed report, and the learnings we can all take from it. The work of this Board will be a lasting tribute to the El Faro 33. And to the families, may God bless you, and you will always be in my heart.”

The American Bureau of Shipping, who surveyed El Faro under the Alternate Compliance Program and served as her class society, was represented by Gerald White.

“Every employee in the company, from the Chairman and CEO, to the surveyors and engineers, remain saddened by the loss of El Faro’s crew. It’s a devastating loss to the families and the entire maritime community. On a personal level, I’ve had the opportunity to meet many of the family members here today. Thank you for sharing your thoughts and concerns. In addition, some of you have met or spoken with Lou O’Donnell the Assistant Chief Surveyor; Tom Gruber, the head of the Stability Group; Dan Croninand Suresh Pisini from the Structures Group; as well as the individual surveyors who perform surveys aboard the vessel in Jacksonville and Puerto Rico. I wish to convey that these representatives of ABS are dedicated to making sure that this investigation by the MBI and the NTSB is both accurate and thorough. To the extent that questions have been raised by family members concerning what ABS does and what its role is aboard the El Faro, we sought to address that. I hope that our explanations and the presentation of our witnesses satisfied your questions and concerns, thank you.”

Herbert Engineering Corporation President Spencer Schilling was not present for the final week of the hearing session, but submitted a statement, which was read by the MBI Chair.

“Herbert Engineering appreciates the opportunity to have been of assistance to the MBI hearings. We look forward to continuing our discussions with Dr. Stettler regarding the MSC report. Of course, we remain available to respond to any post hearing requests from the MBI.”

The investigators themselves also had closing statements. First was NTSB Investigator-in-Charge Brian Young.

“On behalf of the entire NTSB, especially the team conducting this investigation, I want to extend our deepest condolences to the families that have lost the brave loved ones in this tragic accident. We would like to thank Captain Neubauer and the Coast Guard for including our agency in these hearings, and for their exceptional cooperation. We appreciate and want to extend our gratitude to the parties to this investigation for their continued support throughout the last 16 months by providing valuable information, hundreds of documents, technical reviews, granting us access to El Yunque, and supporting our investigation while continuing their daily functions at their respective companies and agencies. We want to thank everybody involved in assisting us to locate and recover the VDR, as it has been instrumental in this investigation. At a future date, a separate report of the NTSB findings will be issued, and it will include our official determination for the probable cause of this accident. We will continue to collect evidence, develop findings, conduct analysis, and issue recommendations based on all the facts developed throughout this investigation. In closing, I would like all the family members, especially all those who have been here day after day over the course of these six weeks of hearings, to know how much this accident has personally affected every single one of us on our team, as many of us have spent decades at sea. Seeing you all here every day demonstrates your dedication to your loved ones and to each other and it further empowers us to ensure that we are doing everything to prevent a similar tragedy from occurring in the future. Thank you all.”

And MBI Chair Captain Jason Neubauer closed the proceedings with his statement.

“Today, the MBI and NTSB investigations are transitioning to the analysis phase. Although there’s always a chance that a short hearing session could be convened if new witnesses are identified as the report is being written, I believe we have gathered the factual evidence necessary to proceed with our analysis. However, the MBI will continue to collect and review any evidence submitted in the future, including submissions to the elfaro@uscg.mil email address. Gathering the evidence over the last 16 months was challenging, due to the wide scope of the investigation. I’d like to take this opportunity to sincerely thank the parties in interest, government agencies, maritime organizations, company representatives, merchant mariners, and individual witnesses who dedicated their time and resources to this monumental endeavor. The collective expertise of those involved in the process has helped to clarify numerous technical and regulatory matters that the maritime industry grapples with on a daily basis. On behalf of the entire Board, I would like to express our deepest condolences to the friends, shipmates, and families of the mariners who were lost at sea during this accident. It has been difficult to watch and listen as the struggle to come to terms with this tragedy continues on a daily basis, especially here in the hearing room it is very visible. But it’s also important for investigators to observe the emotional toll, as it strengthens our resolve, daily. I’ve also been personally inspired by the solidarity and the selfless spirit which has been clearly displayed throughout the MBI process by those impacted by this incident. Your feedback and suggestions have aided the overall investigation, and your commitment to preventing a similar tragedy in the future is noble and appreciated. In closing, I want to emphasize that the members of the MBI are conducting the investigation with a profound sense of duty, to identify the incident’s causes and push for any needed changes to enhance maritime safety. Even though the public side of this investigation is coming to an end, please rest assured that we will work to continue in earnest as a report is drafted and the recommendations are generated. In the interim, I’m confident that conducting the proceedings in a public forum and making them available on the internet, has helped to raise important safety issues that are actively being identified and addressed around the world as we speak today.”