NTSB weighs survival factors in sinking that nobody survived

Survival Factors Group Chairman's Factual Report shows lifeboats would have been able to deploy at experienced list

When El Faro sank in Hurricane Joaquin, none of the 33 people on board survived. It’s a fact that has been a big driver of the investigation, with officials specifically looking in to factors that influenced the survivability of the storm.

More than a year since the ship went down, the NTSB has released a series of factual reports on the sinking, including the Survival Factors Group Chairman’s Factual Report that examines the search and rescue efforts and safety systems on board.

FULL COVERAGE: El Faro sinking

WOKV has worked through this report to bring you the new information and how it fits in with what’s been uncovered in the investigation in to the sinking so far.

First notifications

The first call from El Faro’s Captain came at 6:59AM to TOTE’s designated person ashore, where he left a message describing a “navigational incident”. At 7:02AM, the Captain called TOTE’s contracted emergency call center, describing a “marine emergency”.

AUDIO: El Faro Captain's final shoreside communication

The Captain and DPA were connected at 7:06AM, and while that communication was not recorded, the DPA says they spoke about the blown scuttle, considerable flooding, list, and the ship’s main engine not having power.

At 7:24AM, the DPA contacted the Coast Guard Atlantic Area command center, per protocol. Within about 15 minutes, the Search and Rescue operations unit watchstander at Coast Guard Seventh District Command Center in Miami had called back, telling the TOTE rep to start lining up a tow operation and indicating they would continue trying to contact the ship. Numerous efforts to reach El Faro following those initial communications were unsuccessful.

TOTE's incident command center was stood up in Jacksonville and the American Bureau of Shipping rapid response damage assessment group was established in Houston. Previous testimony in front of the Coast Guard Marine Board of Investigation that's also working the sinking showed that there were some data inconsistencies these groups initially dealt with during their response, specifically with cargo loading.

Initial alerts

El Faro was equipped with a number of systems to use in an emergency situation.

At 7:13AM, an Inmarsat-C distress alert was sent with information about the ship, speed, nature of the distress, and more. This alert was routed through Norway to the Coast Guard Atlantic Area in Norfolk, and then down to Miami. The NTSB Electronic Data Group Chairman’s Report says the alert data wasn’t fully passed from Norfolk to Miami, giving an incorrect initial ship position.

The ship security alert system (SSAS) sent two automated alerts. This is a covert alert that’s generally designed for a security situation, like pirates.

Additionally, El Faro’s emergency position-indicating radio beacon (EPIRB) sent a transmission, which includes registration data about the vessel. This alert did not have GPS data.

Early search and rescue

Coast Guard Miami requested an Air Force hurricane hunter C-130 that was doing Hurricane Joaquin reconnaissance do a fly over of El Faro's last known position around 10:35AM on October 1st. The aircraft made radio callouts and did a radar search, but had negative results. The storm prevented the plane from getting below 10,000 feet.

The Coast Guard then asked for the assistance of another vessel in the area, the Emerald Express, but the Captain declined because his ship was trying to ride out the storm in the lee of the islands, and felt that moving would expose them. The Captain did make radio callouts, but with negative results.

On the second day, October 2nd, a C-130 from Coast Guard Air Station Clearwater took off to conduct a search, but the hurricane- including high winds- continued to hamper their efforts. The weather was so severe, that a fuel leak was discovered on the aircraft when it got back to the base. All additional flights were canceled for the day, because of the danger.

Three Coast Guard H-60 helicopters were deployed to two different locations to support the search once the storm moved. Other assets were readied as well, including two C-130s out of New Jersey and the Coast Guard Cutter Northland.

Further complicating this coordination effort was the fact that two other rescue missions were taking place. The Bolivian ship Minouch was listing 30 degrees after her crane broke loose near Haiti, and the twelve person crew abandoned ship in Tropical Storm conditions on the fringe of Hurricane Joaquin. A stroke patient also had to be medically evacuated from the cruise ship Carnival Pride off North Carolina.

Debris starts surfacing

Even on October 3rd, the search conditions remained "challenging", with low visibility, hurricane force winds, and high swells. Despite that, a C-130 was able to complete a four-hour search, but had negative results.

An HC-130 aircraft located a debris field off Crooked Island, and an MH-60 helicopter found three life rings, including one stenciled with El Faro. A second debris field was later found with items appearing to be packing material.  In all, seven aircraft from the Air Force, Navy, and Coast Guard completed a SAR mission on October 3rd, totaling 28 hours.

By October 4th, the Northland arrived on scene and aircraft continued search and rescue, or SAR. Another cutter and three tugs contracted by TOTE arrived later in the morning to further support efforts. El Faro's sister ship, El Yunque, also searched as it traveled from Jacksonville to Puerto Rico.

El Faro’s starboard lifeboat was found at 3PM, swamped. A rescue swimmer was put in the water, finding heavy damage and nobody on board.  Two life rafts were spotted by a Navy P-8, and while a cutter found one with nobody on board, they couldn’t locate the second one.

GALLERY: Exhibits from the NTSB's factual reports

Just before 5PM, the Navy P-8 spotted an immersion suit forty nautical miles west-northwest of the ship’s last known position. Around 6:23PM, an MH-60 deployed a rescue swimmer, who found the suit contained human remains in “an advanced stage of decomposition”- to the point that identifying factors like race couldn’t be determined. The crew received a report of another immersion suit that may have had waving arms, so they decided not to recover the remains, and instead to move to the new position. A SAR representative told the MBI that, had they recovered the remains, they would have been required to immediately return to the base, instead of checking the report of another suit, and they determined it was more important to continue the search for survivors.

The crew dropped a “self-locating datum marker buoy” with the remains, but it was later determined the beacon didn’t transmit the position, so the remains were never located again. The second immersion suit could not be located when search crews moved to where it had been reported.

The skies finally cleared October 5th, and crews quickly concluded El Faro had likely sunk. SAR crews began recovering survival equipment, including three lifebuoys. Other debris believed to also belong to the ship included a refrigerated container door, personal flotation device, and dozens of toy dolls.

An empty survival suit was recovered the next day, and another empty suit the day after that.

By the end of the day October 7th, 195,601 square miles had been searched in 50 air and surface missions totaling 274 hours. At that point, the Coast Guard suspended the active search, with no survivors found.

SAR frustrations

The early SAR mission was complicated by the fact that the Coast Guard's software had been upgraded in July, and continued to be glitchy. SAROPS is used for search planning, and includes the ability to plug in different scenarios and factors. Coast Guard SAR representatives previously told the MBI that the system would lock up, forcing them to reboot their computers, while they instead mapped things out by hand.

The new NTSB report says SAROPS 2.0 was also limited to winds of up to 40 knots and a vessel of up to 300 feet- where El Faro was 790. Additionally, the case file disappeared during their efforts because of issues with computer servers, and there was no built-in backup.

Safety equipment on board

The NTSB report says the survival system- including the lifeboat, davit to lower the lifeboat, winches to recover the lifeboat, and hook to release the lifeboat- was all original equipment to the ship, from the 1970s. One of the lifeboats is mechanically propelled by a manual Fleming gear and the other by a diesel engine, and both are open construction. The report notes these types of lifeboats are only allowed on ships that were built before 1986.

The annual lifeboat inspection in August 2015 tested the boats and launching appliances. The technician signed off across the board- davits, winches, lifeboats, and hooks. There were some areas of corrosion noted, though, and the technician tasked the crew with cleaning that by a November follow-up. He further recommended replacing the freewheel clutches because they were leaking oil, and replacing the starboard winch clutch because it was making a strange noise.

The freewheel clutches were replaced September 28th and 29th, 2015- the day before and the day of El Faro's final departure- and the work was approved by the technician involved. We learned at the MBI, however, that TOTE never notified ABS or the Coast Guard about the work, meaning it was never properly surveyed as required. The TOTE employee involved says it was "an oversight" to note notify their surveyor. The technician further confirmed to the MBI that, while he was confident in the repair, he didn't actually see both lifeboats get lowered, which they would generally do as part of the final tests on the repairs.

The starboard lifeboat- which was the open, mechanical design- was recovered during the search and rescue. It was swamped, with a fouled propeller, bent propeller blade, and damage to the port and starboard sides of the hull. The other lifeboat wasn't found until the second mission searching for El Faro's Voyage Data Recorder, or black box, when it was located on the ocean floor. One end of the lifeboat had been cut off and hasn't been found, according to the report.

El Faro was required to have three life rafts, but had five on board. The NTSB report says two additional life rafts were put on El Faro’s sister ship, El Yunque, as a precaution because of corrosion to the lifeboat davits, and TOTE decided to add them to El Faro as well “in case a similar situation should arise”. The report says there was a discrepancy between ABS records and life raft inspection records on what type of six-person life raft was on board. The type reported by ABS was apparently removed in May after being damaged by a container.

The transcript of the VDR confirmed, for the first time, that El Faro's Captain had ordered life rafts be put in the water for the crew to abandon ship. One of the life rafts was located during the search operations, but not recovered. None were found in their stowed positions in the wreckage.

No life preservers were recovered during SAR, although 46 were on board, spread between crew cabins, the bridge, the engine room control station, and the bow. Crews did recover four life preservers, but it was determined they were cargo, not the ones used by crew.

Only two of the ship’s 56 immersion suits were recovered, one of which was unzipped, had the left arm inside out, and a tear at the right hip seam. The strobe light and whistle were operational, but off.

Ship records show safety tests, like fire drills, took place as scheduled through August, and many of the systems- like the lifeboat radios- were tested. The September records were not available because they were on board at the time of the ship sinking. The NTSB says there was a monthly safety meeting verified in September.

Open lifeboats

There was no specific mention in the VDR transcript of the lifeboats, however protocol to deploy those was included in the abandon ship procedures. The NTSB report says the lifeboat design is capable of being launched at a 15 degree list, which is the condition the Captain reported for the ship ahead of the sinking.

Because of the age of the ship, El Faro’s lifeboats had different standards than those on ships post-1986. For example, the lifeboats had to be able to be deployed at a 15 degree list, whereas the more modern designs are at 20 degrees. Also because of the age of the vessel, El Faro was allowed to have open lifeboats, instead of enclosed.

When El Faro converted from a strictly roll on/roll off operation to Ro/Con- or also using cranes for deck container storage- TOTE successfully petitioned to not have that considered a "major conversion". Had it been given that classification, the lifeboats would have been held to more modern standard.

The Coast Guard Captain leading the SAR told the MBI he wished the crew would have had an enclosed, self-launching lifeboat. He told investigators the safest place for the crew in those conditions was El Faro, and when that was no longer an option, the enclosed, self-launching lifeboat would have been the safest alternative.

Looking forward

WOKV continues to break down all of the latest information from the NTSB, including reports this week on the engineering history of the ship and electronic data that was recovered in the investigation. Check back tomorrow for new insight on the impact of forecasting errors with this storm.

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