Recapping El Faro sinking investigation as final hearing session begins

El Faro's 'black box' to be a main focus of Coast Guard Marine Board of Investigation public probe

As the final hearing session of the Coast Guard Marine Board of Investigation probing the El Faro sinking gets underway, WOKV is recapping some of the key takeaways from the investigation so far.

This third and final hearing session will take place in Jacksonville and is slated to last two weeks. We’re expecting interviews with 28 witnesses- former crew, TOTE employees, Coast Guard representatives, and other technical experts- and an examination of El Faro’s Voyage Data Recorder. The MBI is working to determine factors that contributed to the sinking, if there’s any evidence of misconduct or negligence, and whether any agency or person contributed to what happened.

FULL COVERAGE: El Faro sinking

GALLERY: NTSB footage of the wreckage of El Faro

All 33 people on board El Faro died when the ship sank in October 2015. It was heavily loaded, had lost propulsion, had taken on water, and had a severe list when it encountered Hurricane Joaquin en route from Jacksonville to San Juan.

NTSB reports

The NTSB has been involved in the MBI investigation, and will participate in the final hearing session as well. While portions of the investigation are collaborative, the NTSB will issue its own findings and conclusions, independent of the MBI.

The NTSB was responsible for the VDR transcription, which they released in December 2016.

It took three missions to locate and recover El Faro's VDR- or black box- from the ocean floor. Part of the problem is, according to the most recent inspection report, the black box beacon may not have been working at the time of the sinking, meaning there wouldn't have been any sound emitted for search equipment to pick up. With the VDR now brought up from the ocean floor, analysis of the device showed that not only was weather, navigation, and other data recoverable, but audio from discussions on the bridge as well. The audio itself will never be released, but the NTSB put together a transcript, which they say is the longest they've done.

As the NTSB made their report on the VDR public, they also released other factual reports on some of their investigative findings so far.  WOKV did an in depth breakdown of each of these reports, which included examining weather information, survival factors, and more.

GALLERY:  Exhibits from the NTSB's factual reports

The MBI has access to the NTSB reports and was involved in much of the investigation behind these documents, but has not met in a formal hearing session since the reports were released.

The NTSB has not made any conclusions at this time. Since the last MBI hearing session, the NTSB Investigator-in-Charge on this case retired. The new lead has been working with the investigative team since the beginning.

Weather forecasting and systems on board

Prior hearing sessions of the MBI have included testimony about the problems both with a weather forecasting system on board and with a tool used in gathering wind data. The company behind one of the main weather systems used on El Faro- the Bon Voyage System- confirmed that a one-time glitch resulted in the ship getting an outdated forecast track in the hours ahead of the sinking.

There were also problems with the forecast track itself for Hurricane Joaquin. The National Hurricane Center confirmed that their forecasting errors were some of the largest they've experienced, and the storm itself was erratic.

The VDR transcript showed the Captain of El Faro changed course twice while on the final voyage- intending to skirt around the track- but he also declined two more suggested alterations that crew made in the hours ahead of the sinking. The transcript further shows that the crew expressed frustration about some of the inconsistent data they were working with.

The NTSB's Meteorology Group Chairman's Factual Report has a detailed discussion of how the crew was able to get weather data- investigators have frequently asked during hearing sessions whether data came to the Captain or a general email accessible from the bridge. VDR data shows there were some lags and gaps in data downloads, and other times data was available, but not requested.

Cargo security

El Faro was heavily loaded at the time of the sinking, and prior testimony from officials involved with the owner and operator of the ship shows they had been dealing with increasing cargo volumes because of a different shipping line closing up.

Prior testimony has also showed that the stevedores who secure the cargo during loading didn't necessarily use manuals and instructions, as much as they relied on experience. Specifically, there has been a lot of discussion- and little consensus- on whether workers had been instructed specifically to use storm lashing because of the expected heavy weather, and what exactly they believed storm lashing to be. A stevedore testified that the ship looked her age on the inside, with areas of rust.

The VDR transcript shows the Chief Engineer was concerned about the quality of the lashing on this final voyage.

The transcript further confirmed, shortly ahead of the sinking, a crew member saw containers in the water, another reported some cars moving in the flooding in one of the holds, there was a sound believed to be cargo crashing in to the bridge, and it was believed by the crew- although not confirmed through their conversations- that other items had broken loose.

To ensure ship stability, the cargo is loaded with the help of a software program that considers factors like cargo weight in mapping out the loading plan. Through the first hearing session, MBI investigators heard testimony that there was some disparity between the software report and the actual conditions, although it was a relatively consistent discrepancy which they crew relied on experience to account for.

Flooding on board

During the Captain's final shoreside communications- which were released during the first MBI session- he reported that they had taken on water and were listing, but he believed the intake had been brought under control. The VDR transcript shows that the Captain attributed the water to a blown scuttle, but that there were other areas of flooding later reported as well.

The crew wasn’t able to gain ground, despite their efforts to pump out the water. In addition to dealing with the flooding, the resulting list was causing problems in their efforts both to pump out the water and restore the plant, according to the crew conversations.

The engine plant

The VDR transcript shows that just a few hours ahead of the sinking, the bridge got a call from the engine room to discuss the list the ship was experiencing and the engine oil levels.

We've previously heard in MBI testimony that boiler components were severely deteriorated and recommended for repair. We've also previously learned that the ship had lost propulsion ahead of sinking. The VDR transcript now confirms the Captain made statements that the entire plant was lost, and while conversations confirmed the engineering staff believed they could get the boiler back, they were struggling because of the list.

The NTSB factual report from the Engineering Group says El Faro had an emergency generator that should have been able to operate at a 22.5 degree list.  The emergency generator had been used in a scheduled plant shutdown in August. The report further says that El Faro’s boiler components should have been able to operate at a 15 degree list.

Polish riding crew

A common thread through the investigation so far has been questions on the Polish riding crew that was on El Faro on this fatal voyage- exactly what work were they doing on board and whether there was a language barrier that prevented them from understanding instructions given by the crew.

The VDR transcript showed that the El Faro crew joked about the Polish riding crew’s comprehension- or potentially lack of- of the storm they were facing. Investigators have been told that there was one person on board assigned to communicate with and oversee the riding crew, and that at least one member of the riding crew had a good enough understanding of the English language to accurately receive and convey information.

The crew was working to prepare El Faro to convert to the Alaskan trade. An official with the ship's operator has testified that the riding crew may have been doing work in the engine room on what would become the fatal voyage.

Inspection protocol

El Faro- and many commercial ships that are sailing today- are inspected through a system called the Alternate Compliance Program. This was developed to recognize the work that class societies are already doing on commercial ships and allow them to do inspections on behalf of the Coast Guard. Through the hearing sessions, however, investigators have heard testimony that the Coast Guard doesn't have enough resources, training, and experienced inspectors, and their oversight of the program suffered as a result. Closely tied to the oversight problem is the amount of time the ship owner gives surveyors and the Coast Guard to notify them to conduct inspections- some testimony has shown that could be as little as days, while it's supposed to be two weeks.

There are also holes and conflicts in the guidelines and regulations over this inspection protocol. While there are some documents designed to address that, including "The US Supplement", the Coast Guard says those documents are not updated as regularly as they should be to reflect the latest guidance from the class societies.

Search and rescue

Beyond the issue with the black box beacon battery, the NTSB Electronic Data Group found early search and rescue efforts were also dealing with inaccurate distress signals from the ship. Their report says one of the distress alerts communicated the wrong ship location and another did not have GPS encoding.

Further frustrating those efforts were problems with recently upgraded software the Coast Guard was using to coordinate search efforts. The upgrades led their systems to occasionally lock up or lose data, meaning much of their early efforts had to be charted by hand.

Shoreside, the company groups assisting in the search and rescue operations were dealing with issues as well. During the second hearing session, investigators heard testimony about "inconsistencies" in the cargo loading data that was being used to run calculations as officials tried to determine if the ship could still be afloat.


The NTSB Survival Factors Group Chairman's Report says El Faro's lifeboats and the system used to lower them were all original to the ship. Because of the age of the ship, El Faro was allowed to have lifeboats which are no longer used by more modern ships. For example, both lifeboats were open construction and able to be launched at a 15 degree list, whereas more modern lifeboats are enclosed and designed to launch at up to a 20 degree list.

Testimony during the first MBI hearing session revealed that there had been work done on the lifeboat system on the day the ship left on the final voyage. While the person who performed the repair was confident in the work, an official with the ship's owner never notified the surveyor about the repair, so it wasn't fully inspected by the proper channels. Testimony during the second hearing session also showed that both lifeboats weren't actually raised and lowered after the repairs were made, which is something that would typically be done to fully test the repairs.

El Faro had five life rafts on board, even though only three were required. The NTSB report says that was a precaution because of corrosion found on El Faro’s sister ship’s lifeboat system. The VDR transcript confirmed that El Faro’s Captain ordered the life rafts be put in the water shortly before he called to abandon ship. One of the life rafts was found during the search, but not recovered. El Faro’s starboard lifeboat was recovered during the initial search and rescue, and half of the port lifeboat was recovered from the ocean floor during a second mission to survey the ship’s wreckage.

Next steps

The MBI will last two weeks, and WOKV will be in the hearing room, bringing you instant updates on Twitter.

After this final hearing session is complete, the MBI and NTSB will issue separate reports with the findings and recommendations, with investigators hoping to prevent a tragedy like this from happening again.

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