NTSB faults El Faro Captain’s decision making, company oversight in sinking that killed 33 people

Jacksonville, FL — National Transportation Safety Board investigators are finding fault in the Alternate Compliance Program inspection protocol, the use of open lifeboats, training and oversight by the El Faro’s owner and operator, the Captain’s decision making, and many other areas, among their findings and recommendations following a more than two year investigation in to the sinking of the Jacksonville cargo ship.

33 people died when El Faro took on water, lost propulsion, and ultimately sank in Hurricane Joaquin.

FULL COVERAGE:The sinking of El Faro

NTSB staff spent all day Tuesday presenting 80 draft findings and 53 draft recommendations, while also fielding questions from Board members. The Board unanimously approved those, although Board Member Bella Dinh-Zarr dissented to an additional finding which said the ship’s officers should have been more forceful in how they communicated deteriorating conditions to the Captain.

They’ve also approved a probable cause for the sinking, which heavily cites El Faro’s Master, Captain Michael Davidson for not avoiding Hurricane Joaquin, failing to use the most recent weather information, and more.

NTSB Board Chairman Robert Sumwalt made it clear from the outset that the investigative staff took on a “herculean effort”, and the work they’ve produced will make a difference.

“This report will be studied by mariners young and old for many years, and I’m confident that this tragedy at sea, and the lessons from this investigation, will help improve safety for future generations of mariners,” he says.

NTSB Investigators gave technical and detailed presentations of Factual Reports they've produced through the course of this investigation, all of which raised some serious questions. Investigator-In-Charge Brian Young also presented a video describing the sinking.

El Faro is one of many commercial vessels that are inspected under the Alternate Compliance Program. This allows the ship's Alternate Class Society- in this case the American Bureau of Shipping- to conduct inspections on behalf of the Coast Guard, in order to better use resources and avoid redundancies.

“Staff believes that the Coast Guard’s Alternate Compliance Program is not effective in ensuring that vessels meet the safety standards required by regulations, and many vessels enrolled in the program are likely to be operating in substandard conditions,” says Young.

ABS tells WOKV they’ve worked closely with the NTSB through this process and will continue to do so.

“While ABS has not yet had the opportunity to review all the NTSB recommendations, ABS supports all recommendations that effectively enhance safety and will continue working with the U.S. Coast Guard on improvements in the Alternate Compliance Program,” says a statement from ABS.

Among the testing that is done, Young is proposing having that go further. With El Faro's sinking, it's believed that the severe list led to a loss of suction in the lube oil sump, and ultimately a loss of propulsion. While the ship operated above the minimal required lube oil levels, they were generally below what's recommended. Investigators believe the crew didn't know about the vulnerability of the lube oil sump suction with a severe list and were not instructed to alter that to accommodate for expected heavy weather.  NTSB investigators want to increase awareness of design factors like that, while also pushing the testing limitations to determine the minimal operating levels to more extreme conditions, including list.

While there was a loss of propulsion, investigators don’t believe the ship lost power.

FULL COVERAGE: Detailing the NTSB Group Chairman's Factual Reports

Another factor in the sinking is the amount of water that got on board, contributing to the list. It's believed water first came in through various openings, but then moved through an open scuttle, although the NTSB has not been able to determine why that scuttle was open. They are now recommending that openings like this be outfitted with remote sensors that would show in a manned area- like on the bridge- whether they are open. The water that got in is believed to have made a large cargo deck more slick, and- when combined with vehicle cargo lashings that did not comply with the company's lashing manual- investigators believe automobiles were able to break loose, and likely hit the fire main that was improperly guarded, and further precipitated the flow of water through the ship.

At the Captain’s orders, the crew tried to offset the initial list by transferring ballast, but when the Captain then turned the ship to use wind to help offset the list as well, the totality led to an overcorrection. The list shifted to the other side, where it was apparently never remedied.

An additional vulnerability that allowed water to get in is the ventilation trunks. NTSB investigators found that the ship’s Certificate of Inspection required those to be open, for the purpose of ventilating cargo holds. They also found, however, that those openings were considered to be watertight or weather tight for the purpose of ship stability- and therefore should have been closed at certain times.

Investigators say they don’t believe the crew was aware of this conflict or vulnerability, and water was likely able to get on to the ship through these openings, in the conditions she was facing. A proposed recommendation would outfight all cargo holds with bilge alarms, to more quickly and precisely detect flooding on board.

The weather conditions are a main factor not only in the sinking, but the ability of the crew to survive once the call was made to abandon ship. Investigators do not believe El Faro's lifeboats were ever launched, and in fact on the Voyage Data Recorder, the Captain can be heard calling for the life rafts to be put in the water.

“If you’re in such extreme conditions, is there any way out at that point?” asked NTSB Member Christopher Hart.

“It was very challenging, but we think the best way to have survived this was to have current equipment, and that would have been enclosed lifeboats, and in particular, the stern-launched lifeboat,” says Jon Furukawa, with the Survival Factors Group.

The open-style lifeboats aboard El Faro are not allowed on more modern ship designs, but they were grandfathered in for the ship. NTSB investigators are recommending all of these vessels be required to have enclosed lifeboats, even the ones that would have to be retrofitted. El Faro underwent a "major conversion" in the 1990s that could have meant their lifeboat system would have needed to be upgraded, but the NTSB staff says it appears that was waived because the ship's lifeboat system itself wasn't changed in the major modification. The NTSB believes work done on El Faro in 2005-06 should have been considered a "major conversion" as well, but was not. That also could have required the lifeboat systems be brought in to the modern era.

Their recommendations also include outfitting crew with personal locating beacons and requiring the ship’s EPIRB to transmit location, in order to aid in search and rescue operations. Investigators say they believe the personal locating beacons would cost about $300-$400 each, and a locating EPIRB would be about $800.

In terms of the information transferred by the beacons, there is inconsistency in how the location data is formatted. The NTSB Board was surprised to learn this was an issue that had never been identified  in the past, but staff has put forward a recommendation that would standardize that, and therefore lead to fewer vulnerabilities during the early phases of search and rescue.

AUDIO: El Faro's Captain describes "marine emergency" in final shoreside communication

The crew may have also been inhibited in their attempt to safely abandon the ship because the Master, Captain Michael Davidson, took too long to muster them, according to the NTSB staff. Mike Kucharski, with the Operations Group, says there were several points where the crew should have been mustered- when flooding was discovered, when the ship lost propulsion, when they were having difficulty with the list, and when the flooding continued to worsen. He says crew could have helped investigate the cause of the flooding and potentially combat it.

“By the time the Captain recognized the ship’s perilious condition and sounded signals to muster and abandon ship, it was too late for the crew to assist and to successfully abandon the vessel,” Kucharski says.

Many of the Captain's decisions are being questioned by the NTSB staff. Captured on the ship's Voyage Data Recorder, or black box, are multiple attempts by officers to have Davidson alter El Faro's course in the hours ahead of the sinking. Davidson turned down those suggestions and- despite receiving multiple calls- did not return to the bridge until a few hours before they ultimately went down.

When asked why Davidson did not heed the warnings from his crew, Carrie Bell with the NTSB’s Human Factors Group said they believe this was because of several factors, including his prior experience with storms in the Alaskan trade and possible overconfidence from having come through risky situations.

DETAILED LOOK: El Faro's Voyage Data Recorder transcript

“By not coming to the bridge as the Mates suggested, and by dismissing their suggestions to change course, the Captain missed opportunities to to reassess the situation and alter the voyage plan.  Given the responsibility of this position and the risk of the upcoming weather, it is difficult to explain how the Captain could have been absent from the bridge while the ship sailed in to a hurricane,” Bell says.

The track and intensity forecasts for Hurricane Joaquin were inconsistent and had a large margin of error and there were issues with some of the processed weather information the Captain was relying on taking hours to come through and- in one case- containing outdated information. Despite that, the NTSB believes there was adequate data available to plan for this voyage. The Board said the Captain's decision to leave on that final voyage with the storm brewing was low risk, but his voyage planning left them heading toward an intersection with the storm from the outset.

Sumwalt questioned the responsibility of the crew in this type of situation to be more forceful in their suggestions. Bell says the focus of investigators was on the need for open communication and mutual respect, which is why one of the recommendations is to provide recurring training on Bridge Resource Management. Nonetheless, Sumwalt offered an additional finding- which was adopted by the Board- which says if the officers had been more forceful and direct in their communication with Davidson, it's possible he could have assessed the situation differently.

Some family members of the fallen El Faro crew were not happy with the vote.

“For him to say the officers wasn’t aggressive enough trying to get the Captain’s attention, that was ridiculous. I mean, three phone calls when the Captain knows there’s a storm- what Captain wouldn’t come out of their room,” Claudia Shultz, the wife of El Faro’s Chief Mate Steve Shultz, told our partner Action News Jax while at the meeting in Washington DC.

That breakdown in Bridge Resource Management is one of the reasons El Faro's owner and operator- which both fall under the TOTE organization- have blame as well under the NTSB report. The company failed to enforce some of its manuals and guidelines, did not provide heavy weather assistance or route planning services, inconsistently evaluated key personnel, did not provide enough training, and other problems.

“The company’s lack of oversight in critical aspects of safety management, including gaps in training for shipboard operations in severe weather, denoted a weak safety culture in the company and contributed to the sinking of El Faro,” says the NTSB’s findings.

TOTE says they have fully supported the investigation and are eager to review the NTSB’s final report.

“The investigation was complex. Assessing the large quantities of records and extensive testimony was a daunting task for these investigative teams. We appreciate the  time and effort both the Coast Guard and NTSB investigators expended in their efforts. The TOTE organization will carefully study the final Coast Guard and NTSB reports of investigation once they are formally issued. We as a company intend to learn everything possible from this accident and the resulting investigations to prevent anything similar from occurring in the future. We will also assist both investigative bodies in communicating lessons learned from the accident to the broader maritime industry,” says a statement from a TOTE Spokesperson.

TOTE further says they remain focused on caring for the families of those who died in the sinking and protecting the mariners at sea now.

There are also several factors that have been ruled out as contributing to the sinking, under the draft findings. It’s not believed there was any failure in El Faro’s hull. There is a significant crack that can be seen on the wreckage where she lies now, but investigators believe that was the result of impact with the ocean floor. The ship also lost the bridge and part of the deck, but that’s also believed to have been a result of the sinking, not a cause.

Additionally, there were five Polish nationals on El Faro performing work to prepare her to convert to the Alaska trade. NTSB investigators say there is no indication the work that riding gang was doing on board contributed to the sinking.

With the NTSB’s investigation done, their attention is shifting to lobbying for change.

“The recommendations we’ve adopted today, if acted upon, will result in a broad range of improvements to the safety or marine transportation. As a result of this investigation we’ve plotted a safer course for future generations of mariners. But it is up to the recipients of these recommendations to make a conscious choice, the right choice, to follow that course,” Sumwalt says.

In all, 29 recommendations have been issued to the US Coast Guard, two to the Federal Communications Commission, one to the National Ocean and Atmospheric Administration, nine to the International Association of Classification Societies, one to the American Bureau of Shipping, one to Furuno Electric Company, and ten to TOTE Services.

FULL LIST: NTSB's findings and recommendations from their El Faro sinking investigation

These recommendations come in addition to several others already issued by the NTSB as a result of this investigation. Those came out earlier this year, directly addressing issues dealing with the safety of mariners at sea in heavy weather conditions. The NTSB issued those recommendations along with the start of the Atlantic hurricane season.

Florida Democratic Senator Bill Nelson was quick to commit to change.

“The El Faro sinking was a tragedy. The NTSB’s findings clearly show that more can be done to prevent this kind of tragedy from happening again.  These recommendations coupled with the Coast Guard’s investigation set out a clear path for improving safety on our ships,” says a statement from Nelson, who is the top Democrat on the Senate Commerce Committee, which oversees the Coast Guard.

Family members want to make sure the talk will lead to action.

“That’s why I’m so heavily involved coming back a nd forth, talking with the Coast Guard,  NTSB, and whoever else I need to talk to- that this cannot happen again,” Rochelle Hamm, wife of El Faro Able Seaman Frank Hamm, told our partner Action News Jax.

“The Congress has the will to enact these as law.  Words and recommendations is fine, but actions speak louder than words,” Glen Jackson, brother of El Faro Able Seaman Jack Jackson told our partner Action News Jax while at the NTSB meeting.

The NTSB fully participated in three two-week hearing sessions held by a Coast Guard Marine Board of Investigation, which has also been probing the sinking. While the two bodies collaborated through much of the investigation, the NTSB also conducted their own interviews and analysis, and has been operating independently since the last hearing session.

The MBI has issued its Report of Investigation, which also found fault in the Captain and El Faro's owner/operator, as well as the American Bureau of Shipping and the Coast Guard itself. The Commandant of the Coast Guard is currently reviewing that ROI to determine which of the recommendations and findings he concurs with and how to create change in those areas. There is no timeline on how long his review will last.

The attorney for El Faro Master Captain Michael Davidson has issued a statement disagreeing with much of the NTSB report.

“We appreciate the efforts made by the NTSB during their investigation of the loss of the El Faro. Unfortunately, the findings made by the NTSB contradict, in part, evidence presented during the U.S. Coast Guard Marine Board of Investigation (“MBI”)hearing. The NTSB’s presentation clearly established that the NTSB overlooked, ignored or was unfamiliar with the facts as established by evidence presented during the 6 weeks of hearings conducted by the MBI.

“For example, numerous witnesses testified during the MBI, including former deck officers and a US Coast Guard shiprider, that Captain Davidson practiced excellent bridge resource management. In addition, contrary to the findings of the NTSB, documentation was submitted during the MBI that established Captain Davidson conducted bridge resource management meetings/drills on a quarterly basis, far exceeding the requirements set forth by regulation. Further, during the voyage Captain Davidson was up on the bridge at least once per hour from 0500 to 2000 the day before the vessel was lost discussing the vessels track line and weather with his officers. The VDR transcript also establishes that he and the Chief Mate, a licensed master as well, spent a significant amount of time exchanging thoughts about the weather and vessel’s trackline including just a few hours before the sinking.

“Much was also said about the last call the Second Mate made to the Captain communicating a course change option. What was not said, however, was the option to change course was previously discussed between the Captain and his Chief Mate and the Second Mate warned the Captain that the option to change course included numerous shallow areas. The VDR transcript also established that prior to the call to the Master, the Second Mate told the AB on watch that the option was very risky.

“The NTSB presentation yesterday completely ignored significant comments made by Brian Curtis, Director of Marine Safety at the NTSB, who previously acknowledged to the trade publication Tradewinds that vessels transit hurricanes. Several witnesses during the MBI, including at least two Masters, testified they sailed through hurricanes. The NTSB staff members and board members repeatedly referenced winds in excess of 100 knots. These references were misleading. The weather data indicates that the vessel never experienced winds above 75 mph and the sea state the vessel experienced was between 23 and 30 feet high. The weather conditions that the El Faro experienced should not have caused the vessel to sink. In this regard, it is noteworthy that Tote’s well respected naval architect concluded, it is likely that the vessel would have survived had the scuttle been closed.

“Accordingly, based on all of the evidence that was presented in this case, it is clear that there was no single primary cause for the sinking – rather it was a combination of many unfortunate contributing factors that caused the sinking,” says the statement from attorney Bill Bennett.