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On Thursday, October 1, 2015, the SS El Faro, a 40-year-old cargo ship owned by TOTE Maritime Puerto Rico and operated by TOTE Services, Inc., was on a regular route from Jacksonville, Florida, to San Juan, Puerto Rico, when it foundered and sank in the Atlantic Ocean about 40 nautical miles northeast of Acklins and Crooked Island, Bahamas. The ship had sailed directly into the path of Hurricane Joaquin, carrying a crew of 33, including 5 Polish contract repair workers. All those aboard perished in the sinking. As part of its accident investigation, the National Transportation Safety Board (NTSB) led a joint effort with the US Navy, Woods Hole Oceanographic Institution, and the National Science Foundation to locate the ship’s wreckage and retrieve its voyage data recorder (VDR). The VDR was pulled from 15,250 feet below the ocean surface in August 2016 during the third undersea mission and yielded more than 26 hours of parametric data and audio files. The NTSB’s accident investigation identified the following safety issues: captain’s actions, use of noncurrent weather information, late decision to muster the crew, ineffective bridge resource management, inadequate company oversight, company’s safety management system, flooding in cargo holds, loss of propulsion, downflooding through ventilation closures, need for damage control plan, and lack of appropriate survival craft. The NTSB made safety recommendations to the US Coast Guard; the Federal Communications Commission; the National Oceanic and Atmospheric Administration; the International Association of Classification Societies; the American Bureau of Shipping; Furuno Electric Company, Ltd.; and TOTE Services, Inc.
TO THE UNITED STATES COAST GUARD: Propose to the International Maritime Organization to amend resolution MSC.333(90) to specify that “normal operations” are defined as when a ship is under way using its main propulsion unit and to assess voyage data recorder problems, including not capturing both sides of internal phone calls on the bridge electric telephone and unrecorded very-high-frequency communications, and identify steps to remedy them.
Original recommendation transmittal letter:
Open - Acceptable Response
36 NM Northeast Crooked Island Bahamas, AO, United States
Tropical Cyclone Information for Mariners
Sinking of US Cargo Vessel SS
Atlantic Ocean, Northeast of Acklins and Crooked Island, Bahamas
Sinking of the US Cargo Vessel
: Illustrated Digest
Addressee(s) and Addressee Status:
USCG (Open - Acceptable Response)
Safety Recommendation History
As discussed in our response to Safety Recommendation M-17-46, our El Faro investigation found that audio quality problems with the VDR data should have been detected and corrected during the required annual inspection; however, these problems were caused by noise pollution that was only present when the ship was in motion, not when the ship was pierside. The first part of this recommendation was intended to address the issue that arises because bridge audio and related VDR data performance testing typically occurs while a ship is pierside, not while it is underway using its main propulsion. Although we agree that MSC.333(90) intends “normal operations” to mean that the ship is underway using its main propulsion system, we do not agree that this phrase needs no further clarification. We believe that, in many cases, inspections are done pierside, despite the MSC’s intended meaning of “normal operations.” Please reconsider your determination that amending VDR performance standards is not necessary to ensure that all ships are performing these inspections while underway using their main propulsion systems. We will also consider alternative actions that ensure that VDR audio quality assessments conducted throughout the world are performed in line with the MSC’s intended meaning of “normal operations.” We note that you plan to propose that the IMO amend VDR performance standards to include all communications between shipboard control stations and both sides of all communications to the bridge, as discussed in the second part of this recommendation. We acknowledge your plan to make this proposal to the IMO, but we emphasize that, to fully satisfy this recommendation, you must also address the first part regarding normal operations. Pending completion of both components of this recommendation, Safety recommendation M-17-47 is classified OPEN--ACCEPTABLE RESPONSE.
-From Karl L. Schultz, Admiral, U.S. Coast Guard, Commandant: I partially concur with this recommendation. We believe that the authors of MSC.333(90) intended "normal operations" to mean that the ship was underway using its main propulsion system. This phrase, therefore, needs no further clarification. We agree that ships should take steps to ensure that the voyage data recorder (VDR) is functioning as intended, including capturing bridge audio and communications audio; however, we do not believe that an amendment to VDR performance standards is necessary to ensure that this is being done by all ships. Capturing both sides of ship's internal phone calls on the bridge is an expanded requirement that would require adoptions by the International Maritime Organization (IMO) and subsequent retrofitting of systems on board all affected ships. We will propose to the IMO that the VDR performance standards be amended to include all communications between shipboard control stations and both sides of all communications to the bridge. I will keep the Board informed of the Coast Guard's action on this recommendation.
On December 12, 2017, the NTSB adopted its report Sinking of US Cargo Vessel SS El Faro, Atlantic Ocean, Northeast of Acklins and Crooked Island, Bahamas, October 1, 2015, NTSB/MAR-17/01. The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov. Among the safety recommendations are 29 issued to the US Coast Guard, which can be found on pages 248–251 of the report. The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number. We encourage you to submit your response to firstname.lastname@example.org. If it exceeds 20 megabytes, including attachments, please e-mail us at the same address for instructions. Please do not submit both an electronic copy and a hard copy of the same response.
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