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Safety Recommendation Details

Safety Recommendation M-17-064
Details
Synopsis: 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.
Recommendation: TO TOTE SERVICES: Establish standard operating procedures for heavy weather that address operational limitations and oil levels in critical machinery to ensure their continued operation.
Original recommendation transmittal letter: PDF
Overall Status: Open - Acceptable Response
Mode: Marine
Location: 36 NM Northeast Crooked Island Bahamas, AO, United States
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA16MM001
Accident Reports: Tropical Cyclone Information for Mariners Sinking of US Cargo Vessel SS El Faro Atlantic Ocean, Northeast of Acklins and Crooked Island, BahamasSinking of the US Cargo Vessel El Faro: Illustrated Digest
Report #: MAR-17-01
Accident Date: 10/1/2015
Issue Date: 2/7/2018
Date Closed:
Addressee(s) and Addressee Status: TOTE Services, Inc. (Open - Acceptable Response)
Keyword(s):

Safety Recommendation History
From: TOTE Services, Inc.
To: NTSB
Date: 10/10/2019
Response: -From Jeff Dixon, President, TOTE Services, LLC: As noted in our initial response dated May 7, 2018, TOTE concurs with the intent of this recommendation. In April 2018 we issued Tote Service's Safety Alert 18-008, forwarding Coast Guard Safety Alert 04-18 regarding compliance with SOLAS and USCG Regulations for operation of main propulsion and essential auxiliary machinery lessons learned from SS EL FARO. Since our last update to you in October 2018, we have completed our review of work performed by Glosten, the Naval Architecture and Marine Engineering firm that we retained to assist us on this issue. With their conclusions, we have updated our standard operating procedures within our Safety Management System (SMS) by creating class specific heavy weather checklists that specifically address operational limitations. Each class of vessel now has within its engineering heavy weather checklist the operating range of oil levels for both main and auxiliary machinery. The checklists indicate required oil levels in millimeters for normal operation as well as minimum levels when anticipating heavy weather. All other precautions that were deemed necessary, when anticipating heavy weather, are also listed in the checklists. We believe Recommendation M-17-64 has been fully and appropriately addressed.

From: NTSB
To: TOTE Services, Inc.
Date: 3/11/2019
Response: In our investigation of El Faro’s sinking, we concluded that the port list, coupled with the vessel’s motion, most likely caused air to enter the bellmouth of the suction pipe to the lube oil service pump, which resulted in a loss of oil pressure that caused the main engine to shut down. According to logbook entries, the level of oil in the main engine had been kept at 25 or 26 inches in the 2 years before the accident. Although your operations manual recommended maintaining an operating level of 1,426 gallons, the El Faro left port on the accident voyage with 1,226 gallons of oil, which corresponds to an oil level of 25 inches. We concluded that the level of lube oil in the main engine sump was not maintained in accordance with the vessel’s operations manual, which increased the propulsion system’s susceptibility to oil pressure loss. Shortly before the main engine shutdown, El Faro’s voyage data recorder (VDR) captured a conversation about a possible 18-degree list. As part of our investigation, the Coast Guard Marine Safety Center modeled and analyzed the lube oil levels in the main engine sump and concluded that, with 1,226 gallons of oil in the sump, the bellmouth opening of the suction pipe to the lube oil pump would break the oil’s surface at an 18-degree port list. At that point, the bellmouth would no longer be submerged in the lube oil and air would enter the pump, causing a vapor lock. Previous El Faro engineers testified that the lube oil in the sump had been maintained as high as 32 inches in the past to keep a safe level. With an oil level of about 32 inches, it is unlikely that the lube oil would have fallen below the bellmouth of the suction pipe that supplied oil to the service pumps, even with the vessel listing as much as 18 degrees. With the bellmouth immersed, the oil supply to the pumps would most likely have continued uninterrupted, the pumps would have continued to supply lubrication oil to the main engine, and the engine would have continued to run for longer than it did in the accident. Our report pointed out that heavy weather poses a risk to critical machinery because it can cause vessel movement that places equipment outside normal operating parameters. To mitigate that risk, operators should provide guidance to their crews on what steps can be taken to reduce the effect of heavy weather. In the accident voyage, the El Faro departed with lube oil levels in the main sump below normal operating requirements, and the crew did not receive guidance about raising the oil level in critical machinery during heavy weather. We issued this recommendation based on our conclusion that if you had provided guidance to the crew about the list-induced operational limitations of the engine, as well as about raising the level of lube oil in the main engine sump before or during heavy weather, the additional quantity of oil in the sump would have kept the suction pipe submerged at greater angles of inclination and increased the likelihood of maintaining propulsion. We note that, to address Safety Recommendation M-17-64, you plan to add engineering focused heavy weather guidance into your safety management system (SMS); specifically, you plan to add checklists that reflect the operational limitations of engineering machinery and precautions to be taken in heavy weather. You will also incorporate into your procedures machine manufacturers’ recommendations regarding operational limitations and oil levels for critical machinery to best ensure their continued operation under adverse circumstances. We acknowledge that you do not believe it is safe or feasible to institute, for example, a blanket policy to raise oil levels above the normal operating limits in anticipation of heavy weather, and that you will specify in heavy weather guidance that relevant oil levels are to be raised to the high end of normal operating range (or other manufacturer-recommended operational limits). The intent of this recommendation is not for you to produce guidance that is inconsistent with machinery manufacturers’ recommendations, but we point out that the El Faro departed with an oil level 15 percent below that specified in your operations manual, and that such low oil levels were typical of the vessel’s operation in the preceding 2 years. We also point out that, during our investigation, previous El Faro engineers testified that the lube oil in the sump had been maintained as high as 32 inches in the past to keep a safe level during heavy weather, with no reported adverse consequences. Revising your SMS to add heavy weather guidance, operational limitations of engineering machinery, and precautions to be taken in heavy weather will satisfy this recommendation. Pending completion of those revisions to your SMS, Safety Recommendation M-17-64 is classified OPEN--ACCEPTABLE RESPONSE.

From: TOTE Services, Inc.
To: NTSB
Date: 10/22/2018
Response: -From Philip H. Greene, Jr., President, TOTE Services, Inc.: As noted in our initial response, TOTE concurs with the intent of this recommendation. In April 2018 we issued Tote Service's Safety Alert 18-008, forwarding Coast Guard Safety Alert 04-18 regarding compliance with SOLAS and USCG Regulations for Operation of Main Propolulsion and Essential Auxiliary machinery lessons learned from the SS El Faro. We indicated in our initial response that we anticipated adding engineering-focused heavy weather guidance to reflect operational limitations of engineering machinery, and precautions to be taken in heavy weather. To this end, we commissioned Glosten, a Naval Architecture & Marine Engineering firm, to perform an onboard assessment and analysis of operational limitations of critical machinery onboard TOTE-owned vessels, namely our Orea and Marlin class vessels. This process is ongoing. Glosten will validate optimum oil levels to be maintained in critical machinery, particularly during periods of heavy weather. Where appropriate Glosten will identify and address any operational limitations to prescribed oil levels, and provide a technical recommendation. They will further assess the existing engineering guidance onboard in this respect, and we will develop checklists and procedures to supplement this existing guidance, as needed, consistent with this safety recommendation. We expect this report by early November 2018, and will identify next steps based on their recommendations. We will keep you apprised of our progress in completing this effort.

From: TOTE Services, Inc.
To: NTSB
Date: 5/7/2018
Response: -From Philip H. Greene, Jr., President, TOTE Services, Inc. and Timothy Nolan, President, TOTE Maritime Puerto Rico: This letter acknowledges the e-mail of February 7, 2018, in which the Executive Secretariat, Office of the Managing Director, National Transportation Safety Board (“NTSB”) formally issued certain safety recommendations to TOTE Services, Inc. (“TOTE”). We have organized our responses below to correspond with the numbered safety recommendations to TOTE contained in the final report. Please note that all of the NTSB’s safety recommendations involve changes to vessel operations or capital improvements that exceed existing minimum standards set by law. Accordingly, as discussed further below, some recommendations, if adopted, may require capital improvements or other changes to vessels that are within the exclusive purview of the vessel owner, not the vessel operator. Accordingly, for vessels we manage that are not owned by one of our affiliated companies, we are contacting these external customers by letter to make them aware of these recommendations, so that they may consider these issues and initiate whatever changes they deem appropriate. Therefore, in many cases below, the response we provide only applies to the vessels that are owned by our affiliated companies. We try to make that distinction clear with respect to each recommendation. Additionally, please note that in our Supplemental Party Submission, submitted to the NTSB on January 11, 2018, we identified a number of factual errors that were stated on the record by certain staff at the NTSB’s Public Meeting. Our intent was for the public record to be clear, but many of the errors we raised were not corrected or otherwise addressed when the final NTSB report was published. In some cases below, we point out these errors, not to be argumentative, but to ensure implementation of the changes we are making to our safety procedures are put in their proper factual and operational context. TOTE Response: TOTE concurs with the intent of this recommendation. Traditionally, operators looked to vessel designers and equipment manufactures to provide general information in the associated operating manuals in regard to oil operating levels. Therefore, TOTE, or any other vessel operator, would rely on the manufacturer’s guidance and expertise to define the precise operational limitations and the optimum oil levels needed to maintain operations of critical machinery for sustained conditions, i.e., heavy weather, that create significant vessel pitch, roll, or list. To address this recommendation, we anticipate adding engineering-focused heavy weather guidance in our Safety Management System (“SMS”), specifically checklists, to reflect operational limitations of engineering machinery, and precautions to be taken in heavy weather. To the extent the manufacturers of machinery have provided recommended operational limitations and oil levels for critical machinery that best ensure their continued operation under adverse circumstances, we will incorporate such manufacturers’ recommendations into our procedures. However, we do not believe it is safe or feasible to institute, for example, a blanket policy to raise oil levels above the normal operating limits in anticipation of heavy weather. (Examples of potential negative outcomes are overfilling, resulting in leakage/spillage; and, in the case of certain equipment configurations, such as the bull gear in main propulsion systems, high oil levels an result in churning and frothing/foaming of the oil.) Accordingly, at a minimum, we will specify in heavy weather guidance that relevant oil levels are to be raised to the high end of normal operating range (or other manufacturers’ recommended operational limits), in order to improve potential reliability during heavy weather. We will keep you apprised of our progress in completing this effort.

From: NTSB
To: TOTE Services, Inc.
Date: 2/7/2018
Response: The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation—railroad, highway, marine, and pipeline. We determine the probable cause of the accidents and issue safety recommendations aimed at preventing future accidents. In addition, we carry out special studies concerning transportation safety and coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members affected by major transportation disasters. 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 10 issued to TOTE Services, Inc., which can be found on pages 253–254 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.