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NTSB weighs survival factors in sinking that nobody survived
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NTSB weighs survival factors in sinking that nobody survived

NTSB weighs survival factors in sinking that nobody survived
Photo Credit: NTSB
El Faro's starboard lifeboat showed a "fouled propeller, bent propeller blade, and damage to both sides of the hull" after arriving at Coasst Guard Air Station Miami. The lifeboat was found swamped in the water with nobody on board.

NTSB weighs survival factors in sinking that nobody survived

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.

Read More

The Latest News Headlines

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More than 15,800 people have died from the virus in Italy, according to Johns Hopkins virus tracking site. There are more than 128,000 confirmed cases. The country recorded more than 4,300 new cases Sunday. However, that number is a decrease from earlier in the outbreak when daily cases topped 6,000.The country has been on lockdown for nearly four weeks. The Associated Press contributed to this report. Washington sending 400 ventilators from national stockpile to New York Update 7:56 p.m. EDT April 5: Gov. Jay Inslee announced Sunday that Washington will be returning more than 400 ventilators from the federal government to help the state of New York, which is experiencing a higher number of coronavirus cases. 'I’ve said many times over the last few weeks, we are in this together. This should guide all of our actions at an individual and state level in the coming days and weeks,' Inslee said. The ventilators were sent from the Strategic National Stockpile, KIRO-TV reported. Washington recently purchased more than 750 of its own ventilators that will arrive over the next several weeks. “Thanks to the mitigation efforts the governor has put in place and the cooperation of Washingtonians, we have seen fewer infections in our communities than anticipated. Our current status allows us to help others who have a more immediate need,' said Raquel Bono, a former vice admiral and director of Washington state’s COVID-19 Health System Response Management. There are more than 7,400 confirmed cases and 319 deaths in Washington state, according to The New York Times. In New York state, there are more than 122,500 confirmed cases and 4,159 deaths. Boris Johnson admitted to hospital with virus Update 6:06 p.m. EDT April 5: British Prime Minister Boris Johnson was admitted to a hospital Sunday because of the coronavirus. He went to the hospital because he still has symptoms 10 days after testing positive for the virus, The Associated Press reported. Officials said the move is a “precautionary step,” the BBC reported. Johnson is expected to stay overnight. Johnson, 55, has been quarantined since testing positive March 26. Tiger at Bronx Zoo tests positive for virus  Update 4:56 p.m. EDT April 5: A tiger at the Bronx Zoo tested positive for the coronavirus. It is believed the big cat was exposed to the virus by an employee at the zoo, accoridng to the U.S. Department of Agriculture. Several lions and tigers were showing symptoms of the virus March 27, but only the one tested positive. All of the big cats are expected to recover. The zoo has been closed to the public since about mid-March. Other animals in the zoo are not showing signs of the virus. Death Valley National Park temporarily closes Update 3:26 p.m. EDT April 5: Death Valley National Park has been temporarily closed, effective Saturday due to public health concerns surrounding the spread of the coronavirus, the National Park Service said on its website. The National Park Service said Daylight Pass and California highway 190 will remain open at the park, which is located in California and Nevada. The order means all park facilities, restrooms, viewpoints, trails, roads, and campgrounds are closed until further notice, according to the website. 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It is manufactured by a company in Bothell, Washington, AGC Biologics, which makes a special molecule that is the key ingredient in the drug, KIRO-TV reported. Scientists at CytoDyn figured out it could work to treat COVID-19, and the first severely sick patients who’ve tried it have shown improvement. The drug is called leronlimab, comes in a vial and is a two-shot-per-week dose over two weeks. It is being tried on 10 of the most critically ill COVID-19 patients at Montefiore Medical Center in New York City, the University Hospital for Albert Einstein College of Medicine. The patients are on ventilators, and some are barely conscious. “The first four patients who were intubated, two were extubated. One of them self-extubated and became alert,” said Nader Pourhassan, the CEO of CytoDyn. Now the two patients are out of the intensive care unit. Pourhassan said when he heard the results, he had to stop what he was doing. “And cried for about five minutes. It was very, very emotional,” Pourhassan said. He said studies show that in the U.S., 85% of COVID-19 patients who end up needing ventilators will die. But the patients who’ve gotten shots of this drug have shown strong results. “All eight patients we’ve analyzed so far – the first eight patients – saw immunological benefits. The FDA immediately allowed us to have a phase two randomized trial. We are initiating that today,” Pourhassan said Friday. He said the results were even seen in COVID patients who only got the shots three days, though it takes two weeks for the drugs to take full effect. Read more here. U.S. cases soar past 312,000, including nearly 8,500 deaths Update 12:53 a.m. EDT April 5: The number of novel coronavirus cases in the United States soared past 312,000 across all 50 states, the District of Columbia, Puerto Rico, Guam and the U.S. Virgin Islands early Sunday. According to researchers at Johns Hopkins University, there are at least 312,146 confirmed U.S. cases of the virus, which have resulted in at least 8,496 deaths. Worldwide, there are 1,203,099 confirmed cases and 64,774 deaths from the virus. U.S. cases outnumber those in any other nation, including the 126,168 reported in Spain and the 124,632 confirmed in Italy. Of the confirmed deaths in the U.S., 3,565 have occurred in New York, 846 in New Jersey, 540 in Michigan and 409 in Louisiana. In terms of diagnosed cases, New York remains the hardest-hit with at least 114,174 confirmed cases, followed by New Jersey with 34,124, Michigan with 14,225 and California with 13,878. Five other states have each confirmed at least 10,000 novel coronavirus cases, including: • Louisiana: 12,496, including 409 deaths • Massachusetts: 11,736, including 216 deaths • Florida: 11,545, including 195 deaths • Pennsylvania: 10,444, including 139 deaths • Illinois: 10,359, including 244 deaths Meanwhile, Washington state has confirmed at least 7,500 novel coronavirus infections, while Texas and Georgia have confirmed at least 6,000 cases each. – The Associated Press contributed to this report.
  • Gov. Jay Inslee announced Sunday that Washington will be returning more than 400 ventilators from the federal government to help the state of New York, which is experiencing a higher number of coronavirus cases. “I’ve said many times over the last few weeks, we are in this together. This should guide all of our actions at an individual and state level in the coming days and weeks,” Inslee said. The ventilators were sent from the Strategic National Stockpile. Washington recently purchased more than 750 of its own ventilators that will arrive over the next several weeks. “Thanks to the mitigation efforts the governor has put in place and the cooperation of Washingtonians, we have seen fewer infections in our communities than anticipated. Our current status allows us to help others who have a more immediate need,' said Raquel Bono, a former vice admiral and director of Washington state’s COVID-19 Health System Response Management. There are more than 7,400 confirmed cases and 319 deaths in Washington state, according to The New York Times. In New York state, there are more than 122,500 confirmed cases and 4,159 deaths.
  • Police in a Louisiana city blared a siren signaling the start of curfew -- unknowing that it sounded similar to the alarm in the horror movie “The Purge.” Crowley police sounded the siren Friday night, prompting complaints from residents familiar with the horror franchise, KATC reported. Chief Jimmy Broussard said he was not familiar with the movies. The department will no longer use any type of siren to note curfew hours, KATC reported. The siren sounded eerily similar to the alarm in the movie “The Purge,” where it signaled all crimes, including murder, were legal for a 12-hour period. The Acadia Parish sheriff distanced his department from the noise. “Last night a ‘Purge Siren’ was utilized by the Crowley Police Department as part of their starting curfew,” K.P. Gibson said in a statement. “We have received numerous complaints with the belief that our agency was involved in this process. We were not involved in the use of the ’Purge Siren’ and will not utilize any type of siren for this purpose.”
  • A tiger at the Bronx Zoo tested positive for the coronavirus. This is the first known infection in an animal or a tiger anywhere, The Associated Press reported. It is believed Nadia, a 4-year-old Malayan tiger, was exposed to the virus by an employee at the zoo, according to the U.S. Department of Agriculture. Several lions and tigers were showing symptoms of the virus March 27, but only the one tested positive. All of the big cats are expected to recover. The zoo has been closed to the public since about mid-March. Other animals in the zoo are not showing signs of the virus. The zoo on Tuesday shared video on social media of the tigers enjoying a swim. Agriculture officials are warning people infected with the coronavirus to avoid their pets, like they would other people. “Anyone sick with COVID-19 should restrict contact with animals, out of an abundance of caution including pets, during their illness, just as they would with other people,” agriculture officials said in a statement. “Although there have not been reports of pets becoming sick with COVID-19 in the United States, it is still recommended that people sick with COVID-19 limit contact with animals until more information is known about the virus.” The Associated Press contributed to this report.
  • A Florida man is accused of torturing a dog before killing it and then placing the animal in a hot oven, authorities said. Vicasso Lara, 24, of Lehigh Acres, was charged with torturing an animal, inflicting pain and serious injury, and causing death, the Lee County Sheriff’s Office said in a news release posted on its Facebook page. “I’m speechless,” Lee County Sheriff Carmine Marceno said in a news release. “This is possibly the most brutal and horrific example of animal abuse my team or I have ever seen.” Deputies conducted a well-being check at a Lehigh Acres residence at 10 p.m. Friday, the Fort Myers News-Press reported. After speaking with Lara and a witness, they responded to another residence, where they saw several pools of blood outside the home and bloody footprints near its rear entrance, the Sheriff’s Office said. Detectives executed a search warrant and discovered the body of a dog in a kitchen oven, which had been turned up to its highest setting, WINK-TV reported. Detectives said the dog had been stabbed and bludgeoned before it was placed in the oven, the television station reported. Lara was arrested early Saturday and booked into the Lee County Jail, according to arrest records. He is due in court May 4.

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