Jacksonville, FL — As part of the NTSB’s investigation of the sinking of El Faro, several groups were formed to examine specific factors, like engineering, meteorology, and more.
Now, the Human Factors Group Chairman’s Factual Report has been released, focusing on many different aspects of personnel on and off the ship, including company oversight and training.
FULL COVERAGE: The sinking of El Faro
El Faro went down in Hurricane Joaquin in October 2015, while heavily loaded and transiting from Jacksonville to Puerto Rico. All 33 people on board the cargo ship died. The NTSB participated in a series of Coast Guard Marine Board of Investigation hearings to publicly question interested parties and vet evidence, but also conducted their own interviews. Both Boards are now working separately to put forward their full investigative findings, with the NTSB's expected out later this year.
As part of their ongoing investigation, the NTSB released several factual reports late last year. WOKV has taken a comprehensive look in to each one.
Voyage Data Recorder Group Chairman's Factual Report: Captain altered course twice, but denied two more changes recommended by crew
Engineering Group Chairman's Factual Report: Boiler components were recommended for service, plant failed on final voyage
Electronic Data Group Chairman's Factual Report: Gaps seen in weather data downloads, but cause unclear
Survival Factors Group Chairman's Report: Open lifeboats allowed because of El Faro's age, both were badly damaged with nobody on board
Meteorology Group Chairman's Factual Report: Challenging storm led to substantial forecast track errors
This latest Report comes soon after four newly transcribed portions from El Faro's Voyage Data Recorder- or black box- were released. The overall VDR transcription is the longest ever assembled by the NTSB, capturing more than 26 hours of audio and data leading up to the sinking.
Credentialing, training, and evaluating the crew
The Report says El Faro’s officers were all trained in compliance with Coast Guard and International Maritime Organization regulations, but the company managing the crewing- TOTE- did not require formal heavy-weather training courses because the Coast Guard didn’t require them. The Report says, since 2003, masters and chief mates have had to takes exams covering some aspects of heavy weather to get their credentials, but El Faro’s master got his before and was grandfathered in without needing to test those criteria.
TOTE says informal heavy-weather training took place. The company did not have anyone dedicated to ship-specific training and records, rather that was overseen by various shoreside personnel, ship masters, and individual mariners.
Senior officers on the ships were required to get annual performance reviews, and other officers and crew got evaluations at the end of each ten-week rotation or if they detached from a ship, according to TOTE policy. The investigation so far has found these were not always done on schedule, though. In fact, the second mate’s most recent evaluation was November 2011, and only incomplete draft evaluations were found for the captain and chief engineer.
The Report goes in to detail on the performance evaluations on record for El Faro’s officers. By and large, the reviews show high marks.
GALLERY: Tributes to the El Faro crew
The captain’s most recent evaluation was considered to be a draft by TOTE, and was partially completed October 2014. The port engineer scored the captain excellent- the highest mark- in all categories, except for “cooperation with technical manager”, which was blank. Comments on the evaluation included praise for the captain’s professionalism, saying that he “handles a diversified and unpredictable crew quite well”. This evaluation had not been signed by the captain or technical manager, nor had it been stamped by TOTE for formal receipt.
The second mate’s most recent evaluation in her performance file was from November 2011, when she was a third mate. At that time, the evaluator said the company should aim to keep her long term. There was no performance evaluation in her file from her time as second mate.
The chief engineer's most recent evaluation on file was also from when he served a different role- first assistance engineer in July 2013. At that time, he got high scores, with comments about his good attitude and work ethic. There was a draft evaluation from October 2014 which dealt with him as a chief engineer and a partially complete evaluation from the same year, but it was not stamped for formal receipt.
This chief mate was hailed as passionate and a good instructor. The third mate was a solid watch stander who had the knowledge and skills to advance. The first assistant engineer was marked “fair” in attention to duty, but was also on his first trip in a newly raised role. The second assistant engineer was praised as “one of the most dependable and hardest working men”. Third assistant engineer number one was valuable and highly reliable, number two was recommended in November 2014 to get better knowledge of the ship and equipment, and number three was new to the company- he joined El Faro the evening they left on what would become the final voyage.
New position assignments
At the time of El Faro’s final voyage, TOTE was heavily involved in launching new LNG ships to replace El Faro and her sister vessel on the Jacksonville-Puerto Rico route. Testimony and records examined by investigators show those decisions were causing hostility on board and leaving El Faro’s captain specifically questioning where he stood.
For the first time, this Report shows El Faro captain’s prior employer- for whom he worked for a few years leading up to 2013- had raised some concerns about him. NTSB investigators requested his performance evaluations and related materials for the most recent two years, and found two letters of warning and a letter detailing a meeting between the captain and management.
The Report says that meeting included discussing overtime for cargo operations, concern of unprofessional or disparaging remarks to non-vessel personnel by vessel officers, perception of the captain disassociating himself from daily activities, and perception of disharmony between the master and senior officers. One letter of warning listed two violations on accident reporting.
“Any further incidents of policy infractions or poor job performance would cause us to have a loss of confidence in you as master within our fleet of vessels,” the letter says, according to the Report.
The other warning letter said the captain failed to notify management of cargo damage. That letter stated that the captain had already been warned more severe disciplinary action could be coming, including termination. The captain submitted his letter of resignation in the month that followed that letter.
Correspondence from TOTE officials who were vetting the captain to potentially lead one of the new LNG vessels also showed concerns about the captain's performance. Emails read during the public hearings show one official had "dwindling confidence" in the captain, and another described him as a "stateroom Captain"- although he later testified that was a stylistic difference, but that he was still an "effective" captain.
Emails show the captain received a verbal warning from TOTE for welding repairs that weren’t carried out, but there were no letters of warning or reprimand on his file with that company.
GALLERY: NTSB Factual Reports exhibits
The crewing decisions were causing friction on board, according to the testimony of off-duty crew and crew spouses. None of TOTE's captains were selected for the new vessels at the time, although El Faro's captain was later brought in for another interview for reconsideration, and it was decided he would be offered the job. Before the captain was informed of that decision, though, TOTE learned about an incident involving a potential violation of the company's no-tolerance alcohol policy by an El Faro crew member, but it was not well documented. The company postponed their final decision on the new vessel, and communications from the captain in the days before the sinking indicate he still didn't have a clear picture what would happen.
The captain himself indicated in communications that he had also not gotten any information from TOTE on why he wasn't chosen for a new vessel on the first pass, and he believed he was improving the culture on TOTE vessels- including helping a ship after drug and Customs issues. There was conflicting testimony whether El Faro's captain would have been asked to stay on with the vessel when it transitioned to the Alaskan trade, as planned.
There was also friction among the rest of the crew over the decisions about the new vessels. While there were non-disclosure agreements for those selected for the new ships, testimony from some crew members showed there was discontent among those who were not selected.
Corporate responsibilities
El Faro was owned by TOTE Maritime Puerto Rico and operated by TOTE Services- both under the umbrella of TOTE Inc.
TMPR was previously Sea Star Line, and during a reorganization under that name in 2012-2013, there were some positions that were cut, including port captains. Port captains used to oversee vessel operations along with the port engineer. Another part of the reorganization included relocating more personnel to Jacksonville.
TOTE testified that the reorganization didn't have a negative impact on the shoreside support they provided to ships, but the Report notes there was some conflicting testimony from others about the actual implications.
The Report says TOTE had considered hiring more employees to specifically assist the Manager of Safety and Operations because of his “extensive duties”, but that didn’t happen ahead of the sinking, and that person continued to carry all of the work. By early 2017, testimony showed some of the responsibilities had been reallocated across other existing employees. The Director of Marine Safety and Services also testified that his time was increasingly focused on TOTE’s new LNG ships, and there was no formal reassignment of the other responsibilities on his plate.
AUDIO: El Faro's captain describes marine emergency in final shoreside contact
When El Faro was in distress and later determined to have sunk, but the search for possible survivors was still ongoing, there was an emergency response team stood up. The Report notes testimony from the Vice President of Marine Operations- who was on that team- saying he didn't know the specific duties of the members of the team. The emergency response team would run scenarios as practice, but none specific to heavy weather, according to NTSB interviews with team members.
While the phone number for the Designate Person- a TOTE official available at all hours for any emergencies or needs on the ship- was posted throughout the ship per the Safety Management System, the only company-provided phone on board was on the bridge. That led to questions in the public hearings about whether safety concerns on board could truly be reported anonymously- since there were always people on watch on the bridge.
There was also an online reporting tool, with information posted on the ship, although an internet connection would be required to use the site. Crew were also not prohibited from having their own cell phones, but connection would be difficult at sea.
Safety on board
TOTE- like other shipping companies- is required to have a safety management system that defines the responsibilities of personnel, safe practice for ship operation, and safeguards against certain risks.
Internal audits of the SMS and International Safety Management code were required at least every 12 months, to be completed by TOTE’s Designated Person. External audits also took place by the ship’s surveyor, the American Bureau of Shipping. El Faro’s most recent internal audit was submitted to the company in June 2015. The DP says he was satisfied the crew knew the SMS, and the SMS itself appeared to be well implemented and documented.
Investigators also reviewed minutes from safety meetings that took place on board. The SMS required monthly safety and security meetings on the ship, and El Faro’s most recent was toward the end of September 2015.
Two human factors influencing safety on board are pace of operations and crew fatigue.
TOTE's competitor, Horizon Lines, downsized in 2012 and completely stopped operations on the Jacksonville-Puerto Rico route in late 2014. TOTE picked up more business as a result, and used barges to supplement the existing ships to carry the increased volume of cargo. Turnover notes showed the cargo load on board was "continually heavy", according to the Report.
The Report says El Faro's captain was known to be able to maintain his schedule, even though TOTE says ship personnel didn't know that was something they tracked. There was also testimony from a few different sources saying the company didn't pressure the crew to keep to arrival times, although a company official admitted in testimony that the owners would get incentives for keeping the ships on schedule.
GALLERY: El Faro's Voyage Data Recorder recovered
The Report says El Faro’s officers were under contract to work 12 hours a day while on the vessel. While the hours for the sinking voyage aren’t available because they were on board, records for two two-week periods just ahead of the sinking show officers logging on average 13 hour days and 12.5 hour days. SIU crew members worked an average of 10.9 hour- and 13 hour-work days in those same time frames, with the Report indicating they were on overtime past an eight hour day.
The captain was required to track work and rest hours to ensure they were in compliance with regulations. Testimony was unclear on who in the company would then further verify, although the Designated Person said every crew member was also responsible for tracking themselves.
The mates would generally get a little relief in port, when a port mate would help oversee cargo loading operations. Records show a port mate was not used in Jacksonville in the final days of El Faro, though. Work/rest records for El Faro's third mate show four violations in the final two months.
“The chief engineer told his wife that he was exhausted from all the maintenance and issues he had in the weeks leading to the accident, stating that it was the worst tour he had been on in terms of maintenance issues,” says the Report, citing an interview done with the chief engineer’s wife.
Interviews with friends of the second mate showed she also complained of fatigue and used over-the-counter medication to help get sleep. Testimony and the VDR transcript also spoke about a former chief mate who had fallen asleep while on watch. Further, the captain had worked a normal ten-week shift that ended July 14th, but was called back after only four weeks off because his relief had resigned.
Operating in severe weather
El Faro used the Bon Voyage System as one of their primary weather systems. The system would map weather conditions along with sea conditions, for a ship to use as guidance for routing. The investigation in to the sinking so far has shown a one-time glitch in BVS led to an outdated forecast track being sent to El Faro on their final voyage, but the larger questions that have emerged include whether all of those who needed to use the system were fully trained and if anyone other than the captain could access all of the needed information.
The Report says there is no evidence BVS users on El Faro had any formal training. Rather, prior deck officers who testified said training was on the job, with manuals and guides readily available.
The captain was heard on El Faro's VDR expressing some difficulty with the consistently changing track of Joaquin, although he also stated he believed they would just get around it. The captain did also make some course changes on the fatal voyage, in an effort to ensure they would skirt the storm.
The BVS system sent the data packages to the captain’s stateroom, and he had to download it to send to the bridge, according to the Report. This addresses another frequent question from investigators during the hearings, which is whether the crew was able to get this information directly on the bridge, even without the captain- it appears that was not the case. While the Report says most data packets were downloaded and sent to the bridge by the captain within an hour of them being received, the packet sent to the ship at 11PM the night ahead of the sinking wasn’t downloaded for five hours and 41 minutes, or 4:45AM the morning of the sinking
TOTE’s SMS did not have many specific procedures for heavy weather, except that the ship’s master monitor and analyze weather along the ship’s track and take proper precautions. Additionally, the chief mate needed to ensure watertight hatches and doors were secure, but there was no outline on how that would be verified, according to the Report.
GALLERY: El Faro's wreckage
If the captain needed to slow the ship's speed or change course because of weather, he was required to tell company headquarters. There was an email from El Faro's captain shown during the public hearings that indicated he was seeking approval to change his route on what would have been the return trip on the fatal voyage, rather than just informing the company of the change. Several TOTE officials repeatedly testified to investigators that permission was not needed, and they were unsure why the captain would have sought it. Rather, they said the captain was empowered to make decisions about voyage planning and vessel operations. There were additionally other communications presented which showed the captain informing TOTE of changes as a "professional courtesy", and even in the email where he appears to seek permission to take an alternate return route, he also told the company he had adjusted his immediate route further to the south to try to get around the storm.
There were no alerts from the company sent about the system that developed in to Hurricane Joaquin, or Tropical Storm Erika before that. TOTE had sent vessels a safety alert about Hurricane Danny earlier that summer, but told investigators the intent there was as a general advisory about the start of the hurricane season and need to review heavy weather procedures.
During Erika, the Report says a TOTE Maritime Puerto Rico employee in Jacksonville did send an email to some shoreside personnel and three captains with details on the Coast Guard preparations for a port closure. A captain later replied some of the steps he was taking because of the storm, and the next day the Designated Person asked the captain for a detailed list of preparedness/avoidance plans and daily updates. The Report says there was no such initial contact or follow up request made during El Faro’s final voyage, but the ship’s captain did send his avoidance strategy to shoreside staff.
Nobody in TOTE was specifically assigned to monitor ships while at sea.
Polish riding gang
Part of the SMS includes that all members of a riding gang are given a full tour of the vessel. El Faro had a Polish riding gang on board on her final voyage, working specifically on preparing the ship to convert to the Alaska trade.
The training logs associated with the riding gang were on El Faro, so not available for the investigation. A Polish worker who was on the ship in the weeks ahead of the final voyage did tell investigators that they immediately went to the captain's office to fill out forms after boarding the ship, and they did get a tour. He did not remember any safety briefing, had not been taken to the lifeboats to see what to do in an emergency, had not put on a lifejacket while on board, and did not know what the ship's emergency signals were. He further testified that the Polish riding gang didn't participate in drills, and instead, kept working. Statements from wives of some of the Polish riding gang further reinforced that they did not go through safety training.
The wives did say the gang thought highly of the off-duty chief engineer who was assigned as their supervisor.
There were no orientation documents or safety signage provided in the Polish language, and there was substantial testimony that showed most of the workers who had cycled through spoke little or no English- although the Report notes it’s not clear about the fluency of the workers on the final voyage specifically. One of the workers would act as the unofficial interpreter, according to testimony.
“It is not clear whether the Polish riding gang understood the safety procedures,” the Report says.
Wives of some of the Polish riding gang members also gave more insight of the conditions on the ship.
"You can't even imagine this old rust bucket I have to board," one of the workers said, according to a transcript of an interview with his wife.
Looking ahead
The NTSB is expecting to release two more factual reports in the coming weeks- the Nautical Operations Group Factual Report and Naval Architecture Factual Report. WOKV will continue to work through the new information and add context from the ongoing investigations, as those documents are released.
NTSB INVESTIGATION: Factual reports examine aspects of ship operations and sinking
The NTSB has already issued ten safety recommendations as a result of their work so far, saying they didn't want to wait until completion because of the start of hurricane season. The recommendations encourage action on a few ket areas in order to improve the safety of mariners at sea.
The full NTSB report is expected out later this year.
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