There are still no conclusions that have been drawn from the ongoing investigations on the sinking of El Faro, which killed all 33 people on board. The National Transportation Safety Board is, however, giving new information on what they’ve learned so far.
The Board has released a 510 page transcript of El Faro's Voyage Data Recorder, or black box, along with four other "Factual Reports" from their ongoing probe of the sinking. Among those reports, one focused on the engineering of the ship, including its history, engine plant, past inspections, and work that had been recommended.
FULL COVERAGE: El Faro sinking
WOKV is working through these reports from the NTSB to recap the important information and highlight the new details. This recap reflects the Engineering Group Chairman's Factual Report.
El Faro was first built in 1975, a Ponce-class vessel serving as the SS Puerto Rico for the Puerto Rican trade. In 1993, the ship became the Northern Lights and was lengthened by 90 feet in a “major conversion”. It served between Washington and Alaska until 2000, when it was chartered by the US government to carry military cargo for Operation Iraqi Freedom through 2003.
The El Faro was born in 2006, when the ship was converted again, this time to a roll-on/roll-off container ship- Ro/Con- meaning cargo was loaded through both ramps serving vehicle decks and cranes loading cargo decks. Following appeal, this was not considered a major conversion by the Coast Guard, however a former El Faro Captain told the Coast Guard Marine Board of Investigation also probing the sinking that he felt the conversion did impact how the ship handled.
From 2006-2008, the vessel ran from the US East Coast to the Middle East. El Faro was mostly laid up from 2008 through 2011, then completely out of service for two years while laid up in Baltimore.
In May 2014, El Faro formally replaced El Morro- which was scrapped- on the Caribbean trade between Jacksonville and Puerto Rico. The ship was set to convert back to pure Ro/Ro service for the Alaskan trade in early 2016, with a drydock period that had been scheduled for soon after what became the ship's final voyage.
She sank in Hurricane Joaquin October 1, 2015, while heavily loaded and transiting from Jacksonville to Puerto Rico.
Engine room components
The factual report says the engine room was multi-level, with the propeller shaft, reduction gear, main condenser, boiler foundations, and more pumps on the tanktop deck in the lower engine room; the operating platform, main turbines, turbo generators, boiler controls, and switchboards on the third deck; and several fans, storage tanks, and heaters in the engine casing above these decks. There was additionally a steering gear system at the stern, an emergency generator on the cabin deck, an emergency fire pump in the number three cargo hold, and ventilation fans, winches, and hydraulically operated watertight cargo doors in cargo spaces.
The control system was tested annually by the ship's crew, according to former crew members. The documentation specific to El Faro could not be provided, however, because it was kept on the ship, according to the report.
The transcript from the ship’s ‘black box’ shows the Captain said the plant had gone down. The emergency diesel generator could automatically start through battery power and provide electrical power “if power to the main bus was lost”, an off-duty chief engineer told the NTSB. The rules El Faro was built under require the emergency generator would have been able to work if the ship were inclined to 22.5 degree list. Logbook entries show the fuel supply tank had 4,800 gallons of diesel fuel- out of a 5,000 gallon capacity- on September 1, 2015, according to the report. The ship’s maintenance history shows the crew used the emergency generator during a scheduled plant shutdown in August, and the generator was operated monthly as part of preventative maintenance.
The lube oil system allowed a standby pump to automatically start if there was a pressure drop in the supply line. When the NTSB toured El Faro’s sister ship El Yunque, they found alarms that would alert to problems in the lube oil system, including if levels were too low or high, or if there was a power failure. The report also says there was eight minutes of reserve oil in a gravity tank in the event of pressure loss, to provide protection as the engine came to a stop.
Through the Captain's final shoreside communication and other information gathered by investigators, it's been previously determined the El Faro had a 15 degree list before she sank. An email cited by the NTSB in this report says the ship's boilers and components would be able to operate with a permanent list of 15 degrees.
During previous public hearing sessions of the MBI, we have learned that boiler components needed service. This NTSB report says El Faro's chief engineer recommended "front wall brickwork repaired or replaced, burner throats renewed, floor brick replaced, and all fire stops repaired". An email obtained by the NTSB further says the port engineer "wanted to start on the work as soon as logistically possible", according to the report.
A starboard boiler survey was performed by the manufacturing company in September 2015 by a man who previously told investigators he had no specific certifications for conducting these inspections. He found the "front waterwall tubes were bowed, the refractory damaged, and the burner throats deteriorated". Further, renewing front wall tubes, brickwork, and burner throats on both boilers was "highly recommended" by Walashek for repair. The condition of the port boiler is believed to have been worse.
Even more work was recommended, including retubing the upper economizer bank in the port boiler, where seven temporary tubes were being used and there were "signs that the upper bank was starting to fail", per the NTSB report. The report says the temporary tubes were installed after water leaks developed in August 2015. While an ABS surveyor and a chief engineer described testing of the tubes, the NTSB could not get record of the testing through the engine logbook or a system used on board to document preventive maintenance called Asset Management Operational System (AMOS). Information presented at the MBI showed the tubes were also tested and run at a lower pressure than it's supposed to be tested, but ABS says the guidelines they use allow the surveyor to have discretion. TOTE has previously emphasized that this work specifically is an efficiency item.
Walashek did not recommend a timeline for conducting the recommended work, but said the system would be fine for another few months. The man who conducted the actual survey admitted to the Coast Guard MBI that he would have wanted the work done right away, but it was not his decision. El Faro’s owners and operators determined work would be done in the pending drydock that would take place in November.
We’ve now learned from the NTSB report that a repair estimate provided to TOTE by Walashek did not include the tube repair or replacement, but TOTE’s estimated budget for the shipyard period did have anticipated cost for “economizer replacement/upgrade- port and starboard boilers” listed as “life extension items”.
Investigators have not to this point directly linked any outstanding repairs to the boiler components to the ship’s loss of propulsion and other issues ahead of the sinking. The transcript of El Faro’s ‘black box’ now shows the Captain said they had lost their plant, and the boiler is specifically named as something the engineers were struggling to get back on. The NTSB says the last water side survey of the propulsion boilers was done by the American Bureau of Shipping in December 2013. While there is a lengthy survey checklist, the report says there were no comments or numerical data to reflect any testing that took place, only comments that one boiler “looked ok” and the other was “in good condition”- and those comments were made as entries in AMOS by the chief engineer.
For the first time, we’re learning about boiler water chemistry reports obtained by investigators, which showed in March 2014, there were “exceptionally high” levels of copper and iron in various components. The testing company, Drew Marine, recommended work to correct this. They further recommended boiler water sides be inspected for signs of corrosion after a test later in March 2014 found the boiler water chemistry had a “very high pH and conductivity”. While logbooks showed boiler chemistry data was recorded daily from December 2014 through September 2015, there was no record of the recommendations from Drew Marine being carried out.
Other maintenance and pending work
At the time of the sinking, there was no overdue or deferred maintenance, according to statements made from former crew to the NTSB investigators. The El Faro port engineer was unaware of any outstanding work orders, telling investigators he hadn’t checked on work order completion status. The director of commercial ship management says he didn’t monitor AMOS activity unless an issue was brought to his attention. Records give a more detailed idea.
The NTSB report says, in 2014, 308 records of various maintenance tasks were entered in to AMOS, 23 of which were under the “unplanned/corrective” class. Up to the sinking in 2015, 435 maintenance records were entered, including 11 that were “unplanned/corrective”.
Both lube oil service pumps needed maintenance, according to the Chief Engineer’s turnover notes from August, which were obtained by the NTSB. The report says that had been identified as something to address in El Faro’s pending shipyard work.
Lube oil for most of the main engine system met manufacturer’s specifications, according to the NTSB and, when tested quarterly, was found to be within normal and acceptable guidelines. The exceptions were the stern tube and strut bearing systems, specifically in the last two years which the NTSB examined.
In January 2014, the oil in the stern tube system was reported “severe”, with elevated lead, tin, aluminum, and silicon levels. High levels of silicon, sodium, and potassium were also reported in the strut bearing system. Recommended action included changing oil and filters, checking for debris, and more sampling. In April 2015, the strut bearing sample was in the alarm state because of high levels of tin, and the most recent sampling in July 2015 continued to show that. The equipment condition was also “evaluated as poor, and the recommendation was to replace the oil”, according to the NTSB report.
Regardless, the scope of work for the scheduled 2015 shipyard had optional inspection and repair of the strut shaft seal assembly and an optional flush of the strut bearing oil system.
Through the prior Coast Guard Marine Board of Investigation hearing sessions, we’ve learned El Faro had a “marine casualty” in March 2015, where the main engine shut down soon after leaving San Juan because a crew member mistakenly closed a valve. This report confirms the shutdown happened because of human error and not a mechanical failure. As a result of this incident, the crew was re-trained and valves were labeled.
This report also details the inspection protocol over El Faro, which has already been the subject of much scrutiny during the Coast Guard MBI hearing sessions. The Alternate Compliance Program allows class societies- in this case the American Bureau of Shipping- to perform inspections on behalf of the Coast Guard, in an effort to avoid redundancies between the two. If there were any conflicting standards in the two inspection protocols, those would be governed by what's called "The US Supplement", which was established to address any conflict or area where there were no regulations defined.
The increasing use of ACP has led to some concerns that have been aired out in the public hearings so far, including that the number of Coast Guard inspectors has diminished and there is increasing difficulty training new ones. The Coast Guard also admits their direct oversight of ACP vessels is not as high, because the class societies do the work and both the Coast Guard and ABS rely on notifications from the owner to trigger their inspections. The Coast Guard also cites a lack of resources as one of the biggest problems. For example, the have not kept pace with updating the Supplement with new annual guidance issued by ABS because of the limited resources available.
In 2009, the Coast Guard had established seven Centers of Expertise in an effort to improve marine inspection and investigation and safety overall, but the Vintage Vessel Center of Expertise- focused on steam propulsion systems of commercial cargo vessels- closed in 2013.
Specifically with El Faro, the ship’s annual survey by ABS was started in January and completed in February. There were no concerns with the emergency generator, bilge alarms, steering gear, and lube oil pumps. Ballast tanks in the number one hold had been rated “poor condition”, and the port tank was found to be detached from the frame in two areas, according to the report. Temporary repairs were not required by ABS, but a permanent fix was ordered by February 2016. As recent as June 2015, various pumps- including the bilge/ballast pumps- and the emergency generator were run, and ABS found no deficiencies. The Certificate of Inspection was issued from the Coast Guard in March.
On the day of the sinking, El Faro was slated to be added to the "ACP Targeted Vessel" list maintained by the Coast Guard. The list is a risk matrix, which reflects "operational controls, port state detentions, overdue deficiencies, major non conformities, marine casualties, vessel service, and vessel age". The incident that pushed El Faro over the threshold to get it on the list was a reported medical emergency, which was previously revealed in the investigation. This NTSB report confirms for the first time that the crew error which resulted in the loss of propulsion and an oil spill connected to the ship would have added points to their matrix as well, but data was not entered in a timely manner because the Coast Guard's system was in transition.
Because El Faro was not yet on the list, there were no operational controls on the ship at the time of the sinking. Being on the list means being subject to additional oversight.
There were 11 crew members in El Faro's engineering department, including six officers who held Coast Guard credentials.
The Chief Engineer graduated SUNY Maritime College in 2003, was most recently credentialed in November 2014, and joined El Faro in August 2015. Evaluations always issued very good or excellent ratings and noted his intelligence, hard work, and good attitude.
The first assistant engineer graduated Massachusetts Maritime Academy in 2005, was credentialed in May 2015, was qualified as chief engineer, and joined El Faro in August 2015. Evaluations from his time on El Morro had several ratings that were fair, good, or very good. During a prior trip on El Faro, he was evaluated mostly as fair or good, with notes that work ethic and communication skills could be improved, and greater attention to detail was needed.
The second assistant engineer was credentialed in March 2012 and joined El Faro in August 2015. He had received several evaluations, including high praises for dependability and a hard work ethic.
The third assistant engineers all got good evaluations as well, including comments on their high skill level and willingness to do requested tasks, although one was told to increase attention to detail. The newest third assistant engineer joined El Faro the evening the ship left on what would be its final voyage. It was his first ship.
WOKV is bringing you all of the information from the reports released by the NTSB. Check back tomorrow for a look at the insight we’re getting from the electronic data that was transmitted from the ship and salvaged from the VDR.