WASHINGTON – While fateful decisions made by the captain of the doomed freighter El Faro were instrumental in the ship's sinking, federal investigators spread plenty of blame around and highlighted multiple safety issues in the maritime industry that contributed to its demise.
It was a confluence of factors that contributed to the sinking of the Jacksonville-based El Faro in the fury of Hurricane Joaquin on Oct. 1, 2015, which killed all 33 people on board, the National Transportation Safety Board announced. The report concluded a 26-month investigation into the worst U.S. maritime disaster in modern history.
Among its findings the NTSB cited Tuesday the El Faro captain's unwillingness to listen to his crew's suggestions to change course from the path of a raging hurricane; a weak corporate safety culture that left crewmembers ill-prepared to deal with heavy weather. It also blamed an old ship with outdated lifeboats, open to the elements and a vessel inspection system that allowed older ships in poor condition to continue operating.
"We may never understand why the captain failed to heed his crew's concerns about sailing into the path of a hurricane, or why he refused to chart a safer course away from such dangerous weather," NTSB Chairman Robert Sumwalt said. “But we know all too well the devastating consequences of those decisions.”
The board issued 53 safety recommendations, which investigators hope will be adopted by the industry, maritime safety inspectors and weather forecasters to make the seas safer for future generations.
The El Faro, which means "lighthouse" in Spanish, sank between Jacksonville and San Juan, Puerto Rico, after losing engine power in the Category 3 storm. The NTSB retrieved the ship's voyage data recorder, or "black box," from the sea floor near the Bahamas, 15,000-feet under the surface. The device held 26 hours of data, including audio of conversations on the ship's bridge as the frantic crew struggled to save the ship and themselves.
Larry Brennan, a maritime law professor at Fordham Law School and retired U.S. Navy captain, said the NTSB's meeting highlighted major safety problems in the entire shipping industry, including the Coast Guard and so-called "classification societies" like the American Bureau of Shipping, or ABS, that are in charge of inspecting vessels for safety.
"El Faro was a worn, aged ship which succumbed to heavy weather in large part because of multiple unseaworthy conditions, poor leadership and bad decisions by the captain, ABS, the owners as well as inadequate surveys and inspections by the U.S. Coast Guard," Brennan said.
Sumwalt ended the daylong hearing by remembering that El Faro in English means the lighthouse.
"The SS El Faro, unfortunately, is no longer with us. Nor is the crew that she had with her on that final voyage. They are gone, and as they say, certainly not forgotten. We hope this tragedy at sea can serve as a lighthouse to guide the safety of marine transportation," Sumwalt said.
REPORT: NTSB's 81 findings, 53 recommendations
VIDEO: Sumwalt's concluding remarks
READ: Audio transcript of El Faro's final hours
While the board found no fault with El Faro Capt. Michael Davidson's decision to leave port in Jacksonville, they did blame his reliance on an emailed weather forecasting system that contained hours-old data, rather than online updates from the National Hurricane Center. Investigators believe, based on his decisions and recorded comments, that he wasn't aware of the delay in the data and that instead of skirting the storm, he sent the El Faro on a collision course with the hurricane.
"Although up-to-date weather information was available on the ship, the El Faro captain did not use the most current weather information for decision-making," NTSB investigator Mike Kucharski said at the meeting, held in Washington, D.C.
The board also criticized the "weak safety culture" of ship owner TOTE Maritime, Inc., including the lack of employee training for dealing with heavy weather situations and flooding. A hatch had been left open, allowing water from the roiling sea to flood an interior hold; this led to the ship tilting, disrupting the flow of oil to the engines. Once the freighter lost engine power, it was at the mercy of battering swells.
El Faro's wind gauge, called an anemometer, was broken and the 40-year-old freighter's open-top lifeboats would not have protected the crew, even if they had been able to launch them. The El Faro was legally allowed to carry lifeboats that expose people to the elements - just like the lifeboats on the Titanic and the Lusitania - due to safety-rule exemptions for older ships.
Whether the crew could have survived Joaquin's punishing winds and high seas had the El Faro been equipped with the closed-top lifeboats used by newer ships is unknown, but NTSB safety investigator Jon Furukawa said it could have helped crewmembers fighting for their lives.
"We believe that would've been the best method of departing the vessel under these conditions. It is still challenging, and we don't know if they would've survived," Furukawa said.
The board is not only recommending closed-top boats for all merchant ships, but also that the entire industry require crewmembers to carry personal locator beacons to better locate them during marine emergencies.
The El Faro had an older emergency position-indicating radio beacon, or EPIRB, which did not transmit global position system coordinates, and that made locating the ship more difficult for search-and-rescue crews. Given the heavy weather, rescuers probably couldn't have reached the ship any sooner, but the board believes the new requirement would help in future sea accidents.
Investigator-in-charge Brian Young said that the ship left Jacksonville with an oil level below what was recommended, but still above the minimum for the ship.
Investigator Eric Stolzenberg said it is also likely that cars on the ship breaking free from their lashings could have hit pipes inside the ship, allowing more water to come in.
The board was also told that the conditions El Faro was going through the morning of the sinking likely would not have allowed for the ship’s lifeboats to be launched. The board was also told that even if the lifeboats had been launched, because those boats were not fully enclosed, they would not have been safe to be in.
Investigator Jon Furukawa said the crew would have had to swim thorough “floating containers, mountainous seas, and sea foam” just to reach the lifeboats.
Among the factors investigators say were not factors in the accident are boilers, steering and electrical systems, the five-man Polish riding crew, medical conditions and medication use, structural failure or a rogue wave. Investigators also said lashing failure and cargo shift were not factors.
However, investigators said they were unable to determine if crew fatigue or drug or alcohol use contributed.
“The El Faro sinking was a tragedy,” said U.S. Sen. Bill Nelson, D-Florida. "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.”
TOTE officials were on hand Tuesday, as they have been throughout the hearings. TOTE spokesman Darrell Wilson issued the following statement after Tuesday's hearing:
We fully recognize the enormous investment required of the United States Coast Guard and the National Transportation Safety Board to investigate the tragic loss of the El Faro. TOTE has fully supported both efforts from the beginning. We are eager to review the Coast Guard and NTSB final reports.
"The investigation was complex. Assessing the large quantity 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.
"TOTE also remains focused, as we have from the start, on caring for the families of those we lost and working daily ashore and at sea to safeguard the lives of mariners. Safety has always been a central focus of our company and will remain so in the future."
Emotional hearing for families of crew members lost
Several of the 33 families who lost loved ones when the El Faro went down made the trip to Washington, D.C., for Tuesday's hearing.
As they heard details of this tragedy over and over again, many said it was made tougher because of the time of year -- with Christmas just two weeks away.
"This is possibly the worst time to bring it out. But I think they were trying to make sure they got it over as quickly as possible," said Robert Green, a Jacksonville pastor whose son LaShawn Rivera was on the El Faro when it sank.
Green said this time of year is always the most difficult, especially for finding out new information about the tragedy.
"On the human side of things, I think we would have preferred to have it come out after the first of the year," Green told News4Jax ahead of Tuesday's meeting.
Toward the end of the eight-hour hearing, there was an emotional few minutes after Sumwalt said, "Had the mates more assertively stated their concerns, in accordance with effective bridge management principles,” the decisions made by Capt. Davidson may have been different.
The comment was enough for Claudia Shultz to walk out.
"I felt that, somehow, all of this was going to be reflected on them. They didn't do a good enough job. And that hurts," said Shultz, whose husband Stebe Shultz was chief mate on El Faro. "That hurts me. I'm sure it's going to hurt my kids listening to this, too."
Sumwalt said his intention wasn't to place blame on any of the ship's officers, but to point to a factor with which three of the four board members agreed.
"We don't point fingers or lay blame. We just want to call the facts the way they are," Sumwalt said.
Some family members still feel like more needs to change.
"To me, I have an issue with one person deciding the fate of everybody else," said Rochelle Hamm, whose husband Frank Hamm died when the ship sank. "I feel that everybody on the crew is credentialed to do certain things. I don't care if you are scrubbing toilets. If you're on that ship, you go on there with some credentials. So I feel like everybody should have a voice."
The NTSB cannot put any of its recommendations into place as regulations, so Green said he hopes the families continue to push forward, asking legislators to turn the NTSB's recommendations into regulations to make sure a tragedy like this doesn't happen again.
The NTSB investigation into the loss of El Faro has cost $5.6 million and amassed 30,500 hours of investigative work.