Coast Guard Marine Board of Investigation “hopeful” for change following two year probe of El Faro sinking

Jacksonville, FL — As the Coast Guard Marine Board of Investigation releases their findings on the El Faro sinking two years after the ship went down in Hurricane Joaquin, the Board Chair is giving us a better idea of the thought and intent behind those recommendations.

IN DEPTH: Coast Guard investigators recommend civil penalty action against El Faro's operator

MBI Chair Captain Jason Neubauer says they identified multiple factors that contributed to the sinking, all of which link back to four parties: El Faro’s Master Captain Michael Davidson; TOTE, as the company over El Faro’s owner TOTE Maritime Puerto Rico and operator TOTE Services; the American Bureau of Shipping, as El Faro’s surveyor under the Alternate Complaince Program; and the Coast Guard. The primary problem, according to the MBI, was the ship’s proximity to the eye of Joaquin.

“The Master misjudged the path of Hurricane Joaquin and overestimated the vessel’s heavy weather survivability, while also failing to take adequate precautions to monitor and prepare for heavy weather. During critical periods of navigation, when watchstanders were looking to the Master for his guidance and expertise, he failed to understand the severity and that the El Faro’s projected closest point of approach was decreasing,” Neubauer says.

While the MBI Report doesn’t impose any penalties on the licenses of active mariners, Neubauer says- had Davidson survived- they would have recommended a negligence complaint against his credentials.

GALLERY:El Faro's wreckage

While Davidson is ultimately responsible for the ship’s navigation, TOTE is responsible for its safe operation. Neubauer says TOTE failed to identify heavy weather as a threat to the vessel and failed to comply with work/rest requirements. He says the Safety Management System was “ineffective” when faced with discrepancies and “insufficient” for supporting the vessel operations while at sea.

The MBI has recommended civil penalty action against TOTE because of the work/rest violations, potential failure to have trained the riding crew, and two instances where repairs were not reported to the appropriate channels. Neubauer says the Officer in Charge, Marine Inspections in Sector Jacksonville will be responsible for that investigation, which he believes could ultimately lead to fines totaling around $80,000.

FULL DOCUMENT: Coast Guard MBI's Report of Investigation

TOTE also shares in responsibility for the condition of the ship, as does the vessel’s authorized class society under the Alternate Compliance Program- the American Bureau of Shipping. Neubauer says ABS failed to meet “expected performance standards under ACP, which is a special inspection program that allows ACS’s to conduct some survey work on behalf of the Coast Guard.

“The use of unqualified surveyors for boiler inspections on the El Faro, the lack of timely communication with the Coast Guard ahead of ACP activities, and the failure of surveyors to identify degraded material condition in key areas aboard the El Yunque- a sister vessel to the El Faro- all raise concerns about ABS’s performance on behalf of the Coast Guard,” Neubauer says.

WOKV asked Neubauer whether he’s comfortable with ABS still performing surveys under ACP at this time.

“The MBI did find some areas that we can improve, and there are several recommendations in the Report that point to areas where we can enhance training, oversee ACS competency, and also be more transparent in the results of the US flagged surveys and inspections that we conduct, specially substandard inspections- where we find vessels are substandard,” he says.

CONTINUING COVERAGE: The sinking of El Faro

The Coast Guard also bears responsibility, according to Neubauer, for a lack of regulatory oversight under ACP. In the case of the extreme wastage that was found on El Faro’s sister ship, El Yunque, and presumed to be on the vessel itself, Neubauer says there was a regulatory failure across the board.

“The problem with those areas is that they were hard to access, and it was missed by not only TOTE, but by ABS and the Coast Guard. The wastage we saw on El Yunque was longstanding, and would have been there for many years. So, we just felt, in the end, something was missed by the entire regulatory system,” he says.

He says the MBI has determined the Coast Guard was wrong to not determine the ship’s conversion from “roll-on roll-off” to also accomodating cargo to be a “major conversion”- something that would have triggered new regulations and reviews on the ship’s operation. Additionally, he says there was apparently some kind of flaw in the design process, which allowed El Faro to operate with a low level of lube oil sump. The MBI has determined that, with the conditions El Faro was facing, that low level likely resulted in a loss of suction, which led to the loss of propulsion, but he says that was a risk the crew was not aware of.

GALLERY: Tributes to the El Faro crew

The MBI Report  and recommendations focus on the Safety Management System, according to Neubauer- making sure the company identifies risks to the crew and vessel and conducts drills to appropriately test that. He says the MBI wants to see the current drill requirements go even further, testing damage control scenarios as well. This is partly due to the MBI’s assessment that the crew didn’t appear to fully know how to appropriately respond to this incident.

Another personnel factor- aside from work/rest hours- is the apparent anxiety on board over TOTE’s selection of crew for their new class of vessels, among other things. To address some of the potential crewing concerns, the MBI is recommending data- including work/rest hours- be periodically sent back to shore while a ship is at sea, in order to prevent one of their frustrations in this investigation, that the crew logs were on board at the time of the sinking.

Additionally, the ship’s age- and the fact that it was therefore grandfathered in under older regulations- was a key focus of the investigation. El Faro was still allowed to have open lifeboats because of her age, although ships constructed after the mid 1980s are required to have fully enclosed lifeboats. Neubauer says there are about 50 deep draft vessels that still have open lifeboats, and that’s something they want to change. He says the lifeboats El Faro’s crew had available were “not an option” in the weather conditions they faced, but they “may have had a chance” with newer models.

GALLERY:Exhibits from the NTSB's El Faro investigation

Families of the 33 people who lost their lives in the sinking were briefed by investigators yesterday at three locations- one briefing in Jacksonville, one in Maine, and one in Poland. Unlike most other MBIs, the ROI is being publicly released before the Commandant issues his final action. The Board tells us they wanted to be transparent and also give the maritime industry the ability to self correct, which is why they sought the exception to release the ROI now.

Neubauer says he’s already seen some corrections in the two years this investigation has run. He says there has been an increased awareness of watertightness, especially on older vessels. The Coast  Guard also launched a heightened inspection program on some ACP vessels, especially older ones. The work done by traveling inspectors ultimately led to three vessels being scrapped and several others receiving “no sail” orders, pending upgrades.

There’s no set timeline for how long the Commandant will take to review the ROI and issue his orders.

El Faro sank October 1, 2015 in Hurricane Joaquin, while heavily loaded with cargo and transiting from Jacksonville to Puerto Rico. The remains of only one of the 33 people on board were located, but because of the ongoing search and rescue operations, those remains were not recovered.

AUDIO: El Faro Captain's final shoreside call describes "marine emergency"

Other recommendations from the MBI include that there be more GPS beacons- including for the crew and VDR- to increase the chance of location after an incident like this. They’re further asking VDR’s be required to capture more information, including the other end of phone conversations- with the current system only recording conversations taking place in the bridge.

El Faro's Voyage Data Recorder- or black box- transcription was the longest ever compiled by the NTSB. It took two missions to find the VDR and a third to salvage it, but the devide ultimately gave investigators more than 26 hours of data, including conversations from the bridge.

The NTSB participated in the MBI hearing process, but is conducting its own investigation. Until now, they've released several factual reports, interview transcriptions, and other information, but their full recommendations will be voted on by the Board in December. They've already put out recommendations about the safety of mariners at sea. They issued that along with the start of hurricane season, saying they didn't want to wait to try to create action.

FULL RECAP:Factual reports from the NTSB's investigation

There were three two-week hearing sessions held in Jacksonville by the MBI, during which dozens of witnesses were called for questioning by the MBI, NTSB, and four "Parties in Interest"- the American Bureau of Shipping, Herbert Engineering, TOTE, and the widow of El Faro's Captain.

All 33 families have previously settled their wrongful death lawsuits against the owner and operator of the vessel.

Overall, Neubauer says the Board feels this investigation is the most important work they will do in their careers, and they’re optimistic it will lead to real change. He says there’s already a team at Coast Guard Headquarters in Washington DC that’s working on the Final Action Memo the Commandant will issue.

“I know that it’s a high priority,” he says.

The attorney for the widow of El Faro's Captain says they disagree with portions of the Report. He, and the other PII's and families, have 30 days to submit their comments to the Commandant for consideration.

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