May 21, 2018 | Susan Napier-Sewell

Monday Accidents & Lessons Learned: The Worst U.S. Maritime Accident in Three Decades

The U.S.-flagged cargo ship, El Faro, and its crew of 33 men and women sank after sailing into Hurricane Joaquin. What went wrong and why did an experienced sea captain sail his crew and ship directly into the eye of a hurricane? The investigation lasted two years.

One of two ships owned by TOTE Maritime Inc., the El Faro constantly rotated between Jacksonville, Florida, and San Juan, Puerto Rico, transporting everything from frozen chickens to milk to Mercedes Benzes to the island. The combination roll-on/roll-off and lift-on/lift-off cargo freighter was crewed by U.S. Merchant Marines. Should the El Faro miss a trip, TOTE would lose money, store shelves would be bare, and the Puerto Rican economy would suffer.

The El Faro, a 790-foot, 1970s steamship, set sail at 8:15 p.m. on September 29, 2015, with full knowledge of the National Hurricane Center warning that Tropical Storm Joaquin would likely strengthen to a hurricane within 24 hours.

Albeit with modern navigation and weather technology, the aging ship, with two boilers in need of service, with no life vests or immersion suits, was equipped with open lifeboats that would not be launched once the captain gave the order to abandon ship in the midst of a savage hurricane.

As the Category 4 storm focused on the Bahamas, winds peaking at 140 miles an hour, people and vessels headed for safety. All but one ship. On October 1, 2015, the SS El Faro steamed into the furious storm. Black skies. Thirty to forty foot waves. The Bermuda Triangle. Near San Salvador, the sea freighter found itself in the strongest October storm to hit these waters since 1866. Around 7:30 a.m. on October 1, the ship was taking on water and listing 15 degrees. Although, the last report from the captain indicated that the crew had managed to contain the flooding. Soon after, the freighter ceased all communications. All aboard perished in the worst U.S. maritime disaster in three decades. Investigators from the National Transportation Safety Board (NTSB) were left to wonder why.

When the NTSB launched one of the most thorough investigations in its long history, they spoke with dozens of experts, colleagues, friends, and family of the crew. The U.S. Coast Guard, with help from the Air Force, the Air National Guard, and the Navy, searched in a 70,000 square-mile area off Crooked Island in the Bahamas, spotting debris, a damaged lifeboat, containers, and traces of oil. On October 31, 2015, the USNS Apache searched and found the El Faro, using the CURV 21, a remotely operated deep ocean vehicle.

Thirty days after the El Faro sank, the ship was found 15,000 feet below sea level. The images of the sunken ship showed a breach in the hull and its main navigation tower missing.

Finally came the crucial discovery when a submersible robot retrieved the ship’s voyage data recorder (VDR), found on Tuesday, April 26, 2016, at 4,600 meters bottom. This black box held everything uttered on the ship’s bridge, up to its final moments.

The big challenge was locating the VDR, only about a foot by eight inches. No commercial recorder had ever been recovered this deep where the pressure is nearly 7,000 pounds per square inch.

The 26-hour recording converted into the longest script—510 pages— ever produced by the NTSB. The recorder revealed that at the outset, there was absolute certainty among the crew and captain that going was the right thing to do. As the situation evolved and conditions deteriorated, the transcript reveals, the captain dismissed a crew member’s suggestion that they return to shore in the face of the storm. “No, no, no. We’re not gonna turn around,” he said. Captain Michael Davidson then said, “What I would like to do is get away from this. Let this do what it does. It certainly warrants a plan of action.” Davidson went below just after 7:57 p.m. and was not heard again nor present on the bridge until 4:10 a.m. The El Faro and its crew had but three more hours after Davidson reappeared on the bridge, as the recording ends at 7:39 a.m., ten minutes after Captain Davidson ordered the crew to abandon ship.

This NTSB graphic shows El Faro’s track line in green as the ship sailed from Jacksonville to Puerto Rico on October 1, 2015. Color-enhanced satellite imagery from close to the time the ship sank illustrates Hurricane Joaquin in red, with the storm’s eye immediately to the south of the accident site.

The NTSB determined that the probable cause of the sinking of El Faro and the subsequent loss of life was the captain’s insufficient action to avoid Hurricane Joaquin, his failure to use the most current weather information, and his late decision to muster the crew. Contributing to the sinking was ineffective bridge resource management on board El Faro, which included the captain’s failure to adequately consider officers’ suggestions. Also contributing to the sinking was the inadequacy of both TOTE’s oversight and its safety management system.

The NTSB’s investigation into the El Faro sinking identified the following safety issues:

Captain’s actions
Use of noncurrent weather information
Late decision to muster the crew
Ineffective bridge resource management
Company’s safety management system
Inadequate company oversight
Need for damage control plan
Flooding in cargo holds
Loss of propulsion
Downflooding through ventilation closures
Need for damage control plan
Lack of appropriate survival craft

The report also addressed other issues, such as the automatic identification system and the U.S. Coast Guard’s Alternate Compliance Program. On October 1, 2017, the U. S. Coast Guard released findings from its investigation, conducted with the full cooperation of the NTSB. The 199-page report identified causal factors of the loss of 33 crew members and the El Faro, and proposed 31 safety recommendations and four administrative recommendations for future actions to the Commandant of the Coast Guard.

Captain Jason Neubauer, Chairman, El Faro Marine Board of Investigation, U.S. Coast Guard, made the statement, “The most important thing to remember is that 33 people lost their lives in this tragedy. If adopted, we believe the safety recommendations in our report will improve safety of life at sea.”

On October 13, 2017, All Things Considered NPR Host Robert Siegel interviewed Coast Guard Captain Jason Neubauer about the sinking of the El Faro in 2015.*

ROBERT SIEGEL, NPR Host: In the early morning of October 1, 2015, the 790-foot cargo ship El Faro began taking on water as it sailed into Hurricane Joaquin, at that time a Category 3 storm in the Bahamas. A little after 7 a.m., the ship’s captain, Michael Davidson, made an emergency call to shore.

MICHAEL DAVIDSON (voice recording of El Faro Captain): I have a marine emergency, and I would like to speak to a QI. We’ve had a hull breach. A scuttle blew open during that storm. We have water down in three holds with a heavy list. We’ve lost the main propulsion unit. The engineers cannot get it going. Can I speak with a QI, please?

SIEGEL: A QI is a qualified individual, an emergency point person that shipping companies must have onshore. Within the hour, all contact with El Faro was lost. The ship was found a month later 3 miles under the sea. All 33 crew members on board died. The Coast Guard spent the last two years investigating what went wrong and why an experienced captain sailed his ship directly into the eye of a hurricane. It released its findings last week. And joining us now is Captain Jason Neubauer, who chaired the Coast Guard’s investigation. Welcome to the program.

JASON NEUBAUER: Thank you for having me.

SIEGEL: A year after El Faro was found, its voyage data recorder was retrieved. That’s like the black box on a plane. It records what happens on the bridge. What did the recording tell you about the ship’s final hours?

NEUBAUER: The recording actually gave us 26 hours of bridge audio data that we used to kind of recreate the last day of the vessel’s voyage.

SIEGEL: And do you hear anybody saying, we shouldn’t be going in this direction; there’s a hurricane out there?

NEUBAUER: There were conversations, including the officers on board and some of the able seamen that were at the helm of the vessel. Several crew members were voicing concerns very early on from the voyage data recorder started recording.

SIEGEL: And what does the captain say?

NEUBAUER: The captain was confident that they could get south of the storm and not experience the full force.

DAVIDSON: Obviously we know what happened in the end, so we know that that was not the right calculation. Was it a reasonable – I mean, based on experience, was it a reasonable calculation by the captain, or was it an unreasonable one?

NEUBAUER: Well, the board determined that, especially with an erratic storm like Hurricane Joaquin was, that it was imprudent to make that decision.

SIEGEL: The ship, El Faro, was a steam ship from the 1970s, and the report found problems with its safety protocols. Is this accident shining a light on the practice of grandfathering, meaning that old ships – this would be an old ship – don’t have to meet modern safety standards unless they undergo a major reconstruction? Shouldn’t old ships be precisely the ships that need to be updated?

NEUBAUER: That’s the board’s determination, that there has been some grandfathering. One of those big issues is the open lifeboats that the El Faro had.

SIEGEL: Open lifeboats.

NEUBAUER: Yes, Sir. That’s the older-style lifeboat, including one that was hand-propelled.

SIEGEL: Did the crew of El Faro board lifeboats? Did they try to take the lifeboats?

NEUBAUER: The lifeboats – from our analysis and then from experts looking at them, it looks like they were never taken out of the cradle.

SIEGEL: As a Coast Guard officer, have you been at sea in a hurricane?

NEUBAUER: No. I’ve been at sea in heavy weather but not in hurricanes.

SIEGEL: It sounds pretty horrifying.

NEUBAUER: Yes. The board read some accounts from other mariners that have been in a hurricane. Some of the problems that occur is you can’t see the surface of the water. You know, there’s so much sea spray. And we think that under those conditions, it would be almost impossible to, you know, egress from the ship safely.

SIEGEL: Are there lots of other ships as old as El Faro out there?

NEUBAUER: We determine there are about 50 U.S.-flagged deep draft vessels that have the outdated or the older lifeboats arrangement.

SIEGEL: Do you come away concluding that the sinking of El Faro was a rare one-off event that reflected some very odd conditions and decisions, or is it something that we should take seriously as a – something that could go wrong with other older vessels out there?

NEUBAUER: I absolutely think that it could go wrong with other older vessels in the fleet. In this case, we had a nonstandard storm. You know, it formed – it was very unusual. It was late season. So I think if similar storms occur in the future, there’s a possibility that another deep draft vessel could get caught and have to sail through.

SIEGEL: Captain Neubauer, thank you very much for talking with us.

NEUBAUER: Thank you for the opportunity to be here and also for covering this incident investigation.

*Investigators Find Out Why the El Faro Cargo Ship Sank, October 13, 2017, 5:28 PM ET, All Things Considered.

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