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Coast Guard releases El Faro investigation report

Report identifies causal factors of loss of El Faro, 33 crew members

JACKSONVILLE, Fla. – A Coast Guard report released Sunday says the primary cause of the 2015 sinking of the cargo ship El Faro, which killed all 33 aboard, was the captain misjudging the hurricane's strength and the ship's sturdiness.

The report said Capt. Michael Davidson should have changed the El Faro's route between Jacksonville, Florida, and San Juan, Puerto Rico, to avoid Hurricane Joaquin's 150 mph (240 kph) winds and when the 790-foot (240-meter) vessel got stuck he should have taken more aggressive measures to save it. Neubauer said the Coast Guard would have sought to revoke Davidson's license if he had survived.

Davidson "was ultimately responsible for the vessel, the crew and its safe navigation," said Coast Guard Capt. Jason Neubauer, who chaired the investigation. He said Davidson "misjudged the path of Hurricane Joaquin and overestimated the vessel's heavy weather survivability while also failing to take adequate precautions to monitor and prepare for heavy weather. During critical periods of navigation ... he failed to understand the severity of the situation, even when the watch standards warned him the hurricane was intensifying."

The report also says the ship's owner, TOTE Maritime Inc., had not replaced a safety officer, spreading out those duties among other managers, and had violated regulations regarding crew rest periods and working hours. The Coast Guard said it will seek civil actions against TOTE but no criminal penalties as there was no criminal intent.

"We felt from the VDR that the master likely felt that there was no option to abandon ship and he really felt the only option and just stay with the ship until the very end," Neubauer said.

Investigators also found that the ship left with a lube oil level of 24.6 inches lower than the recommended level of 27 inches. That reduced the crew’s ability to maintain oil suction for the main propulsion unit, which began developing problems just after 4:30 a.m.

The report places TOTE, the captain and even the National Hurricane Center at fault. Below are some of the findings:

  • TOTE did not ensure the safety of marine operations and failed to provide shoreside nautical operations supports to its vessels. 
  • TOTE did not identify heavy weather as a risk in the safety management system and the Coast Guard had not exercised its flag state authority to require identification of specific risks.
  • TOTE and the master did not adequately identify the risk of heavy weather when preparing, evaluating and approving the voyage plan prior to departure on the accident voyage. 
  • TOTE and the master and ship’s officers were not aware of vessel vulnerabilities and operating limitations in heavy weather conditions. 
  • TOTE did not provide the tools and protocols for accurate weather observations. The master and navigation crew did not adequately or accurately assess and report observed weather conditions.
  • TOTE did not provide adequate support and oversight to the crew of El Faro during the accident voyage. 
  • The National Hurricane Center created and distributed tropical weather forecasts for Tropical Storm and Hurricane Joaquin, which in later analysis proved to be inaccurate. Applied weather technologies used these inaccurate forecasts to create the BonVoyage System weather packages. 
  • The master and deck officers were not aware of the inherent latency in the BVS data when compared to the NHC forecasts. Additionally, the master and deck officers were not aware that they received one BVS data package with a redundant hurricane track line. 
  • The master and deck officers relied primarily on graphical BVS weather forecasts rather than the most current NHC data received via SAT-C. El Faro crew did not take advantage of BVS’s tropical update feature and the ability to send BVS weather information directly to the bridge.

The report also found numerous systemic violations of rest hours for deck officers that were not addressed by TOTE. The following are some of the standards violations that could be subject to civil penalties:

  • No safety orientation or Coast Guard-approved basic safety training was given for the Polish riding crew.
  • Failure to notify the Coast Guard of repairs made to lifesaving gear.
  • Failure to notify the Coast Guard or ABS of repairs to the ship’s main propulsion boiler superheating piping on Aug. 24, 2015.

TOTE Maritime released a statement Sunday saying the report "is another piece of this sacred obligation that everyone who works upon the sea must study and embrace. The report details industry practices which need change."

The El Faro went down on Oct. 1, 2015, in 15,000 feet (4,570 meters) of water near the Bahamas.
Voice recordings recovered from the ship show an increasingly panicked and stressed crew fighting to save the ship after it lost propulsion as they battled wind, shifting cargo and waves.

Family members of the El Faro crew members gathered for a vigil at the Seafarers Union Hall in Jacksonville Sunday.

For two years, the families have adjusted to life without their loved ones.

“If anyone was to ever go through this, they have to be very spiritual and believe in God, and that's the only thing I can really say, because this is what got me through the whole process -- prayer, and that changed everything,” Marlena Porter, the wife of James Porter Jr., said.

From faith to family and friends, all of the people affected by the el Faro tragedy have found ways to heal.

The Coast Guard's announcement Sunday of what caused the ship to sink hasn't changed their mission. The crew members' loved ones are pushing for changes in the maritime industry, and they said they're already seeing progress.

“People are dealing with it and trying to take the pain and turn it into purpose,” one person at the vigil said. “I mean, now you're seeing results because there are people -- you know, children are getting older, people have formed other relationships they've forged with each other.”

The family members have said they want to see increased safety measures and new practices to prevent another tragedy from happening to other families.

“We have to do the work here so that their loss is not in vain,” another person at the vigil said. “Because there are still other mariners that have to come after them, so the whole thing is for this to never, ever happen to anybody else. That's the main thing."

“I have family that's out there, and I still have my nephews, my cousins that are out there, that's shipping, so the change needs to be made as far as them going out there into that type of weather condition,” Porter said. “I feel like change will be made and it's up to us to get it done.”

Some family members pointed out that changing regulations can often take years, but said it will be worth the wait.

U.S. Sen. Bill Nelson (D-FL) issued a statement following the report's release:

"Our thoughts and prayers remain with the families of those lost on the El Faro. This tragedy never should have happened, and the findings in this report will serve as a roadmap for how we can prevent this kind of tragedy from happening again."

Davidson ordered the ship abandoned shortly before it sank but its open-air lifeboats likely would have provided insufficient protection, the Coast Guard said. The agency said it would recommend that all ships now be equipped with modern enclosed lifeboats.

Click here to read the full report. 


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