Originally published in Castine Patriot, October 5, 2017
Final El Faro report shows industry-wide problems
by Faith DeAmbrose
Almost two years to the day that cargo ship El Faro sank in a hurricane near the Bahamas, the Marine Safety Board issued a 199-page report that laid out a multi-faceted failure leading to the event that claimed 33 lives, including four Maine Maritime Academy graduates, on October 1, 2015.
Human error, complacency, fatigue, missteps and an unpredictable storm were all believed to have led to the accident, according to the report.
A reorganization, amounting to a downsizing, that replaced a “team of managers” with “a single person” to ensure loading was handled correctly at the dock to manuals, standard operating procedures and official policies that were neither followed nor in some cases taken seriously were all highlighted in the report. During voyage, the second mate noted: “Nobody ever takes these—the drills—seriously,” while having a discussion about survival suits and emergency response.
Those with El Faro parent company TOTE Services said the company was “strained by resources” and that the company was looking at ways to reduce staffing further.
The report also found possible problems with inspections not fully conducted and a lack of actual testing of crews on emergency measures.
Manuals, both from TOTE and the USCG, outlined real world practices, but in many instances, the investigation discovered they did not match what actually happen on board the ship or at loading docks.
As the fated ship took off from Florida on September 29, a tropical storm was developing and the ship’s captain, Michael Davidson, an MMA grad (called Master throughout the report), directed the course southward on the “normal route” from Florida to San Juan. Even after updated information showing that the storm was headed into the ship’s path was shared with a sleeping captain less than six hours before El Faro sank, the captain did not come to the bridge and did not utilize the new information to chart a different course.
As a result the Marine Board of Investigation recommended four civil penalties against TOTE Services, including:
Failure to comply with the work-rest requirements…for El Faro crew members on multiple dates prior to the accident voyage;
Failure to comply with emergency procedures for special duty personnel;
Failure to notify the Coast Guard or American Bureau of Shipping of repairs to primary lifesaving appliances [life boats] that were conducted just prior to departure;
Failure to notify the Coast Guard or ABS of repairs to El Faro’s main propulsion boiler superheating piping on August 24, 2015.
The findings also concluded that the Marine Board of Investigation does not recommend any administrative or punitive action against any Coast Guard personnel; does not recommend suspension or removal of any credentialed mariner; and does not recommend criminal prosecution against any person or entity.