NTSB El Faro Report Meeting

This is from the CG MBI report

Part of the DOC audit included a general walk-through of EL YUNQUE, and the Traveling
Inspectors requested that TOTE open up a starboard exhaust ventilation trunk serving cargo Hold 3 for inspection. The Traveling Inspectors noted severe corrosion within the ventilation trunk and they subsequently conducted testing of the soundness of the internal structure of the trunk.

This test, which was performed in a typical manner using a hammer, resulted in a hole through
baffle plating that was required to be watertight (see Figure 27). As the Traveling Inspectors
were discussing expansion of their inspection to additional ventilation trunks, the senior
Traveling Inspector received a cell phone call from the Sector Jacksonville Commanding
Officer. The Sector Commander, as the OCMI for the Port of Jacksonville, ordered the
Traveling Inspectors to stop further inspection and hammer testing of EL YUNQUE’s ventilation trunks because it exceeded the scope of the DOC audit; the Traveling Inspectors complied with that order. However, the Senior Traveling Inspector suspected that the potential for long-standing corrosion existed for the other ventilation trunks and voiced a concern that the wastagecould present a down flooding risk if the vessel experienced severe rolls. As a result, theTraveling Inspectors requested that Sector Jacksonville conduct a follow-up inspection to checkadditional trunks for conditions similar to that of Hold 3’s starboard exhaust vent trunk.
Traveling Marine Inspectors during a February 1, 2016, DOC audit of TOTE.
Under ACP protocols, Sector Jacksonville’s Marine Inspector conferred with ABS and
requested they oversee repairs to the ventilations trunks for Hold 3, check the condition of the
other ventilation trunks, and issue conditions of class as necessary. ABS concurred with the
Marine Inspector’s concerns and required de-scaling and temporary repairs to the ventilation
trunk casings that were identified as corroded during the DOC audit. On February 2, 2016, ABSsurveyed temporary repairs to the holed and wasted areas in way of the port and starboardexhaust ventilation trunks for Hold 3 146 including the following items:

The lower 24” of the louver chamber’s inboard bulkhead was cropped and renewed.
An opening around the side shell longitudinal angle in the transverse baffle plate was
Drainage holes on both port and starboard trunks (smaller and larger) were satisfactorily
closed up.

The ABS surveyor gave TOTE 30 days, until March 2, 2016, to make permanent repairs to
the Hold 3 ventilation ducts and EL YUNQUE continued to operate between Jacksonville and
San Juan. On February 9, 2016, ABS advised Sector Jacksonville that the temporary repairs had been completed to EL YUNQUE’s port and starboard ventilation trunks that were identified as corroded on February 1, 2016. In March 2016, TOTE relocated EL YUNQUE to Seattle,
Washington and started the process of converting the vessel back to its original RO/RO
configuration for Alaskan service.

During MBI testimony on May 19, 2016, the ABS surveyor who conducted the February
2016, repair survey on EL YUNQUE stated the following when asked if problems were detectedin other ventilation trunks:

So after this was discovered we looked at the port side as well and then we
sampled other trunks to verify that they were in good condition. This one that you have
pictures of is the only one that was found in this condition with regards to the corrosion.
From March 18 to August 14, 2016, Coast Guard Sector Puget Sound Marine Inspectors
made several visits to EL YUNQUE and, despite the February 2016, ABS survey and testimony
from the ABS surveyor, recorded the following pertinent findings:

April 6-12, 2016: Directed extensive third party gauging for multiple suspect locations
on the main deck. Found evidence of long-standing and uncorrected wastage.
May 20, 2016: Examined supply vents for the Holds 1-3 port and starboard (6 total).
Observed gaskets missing; holes in vent ducts; gasket flanges wasted; and holes in the
side shell in way of vent inlets (see figure 28). Required all items to be added to the work

August 14, 2016: TOTE halted work and requested to place the vessel in a lay-up vessel
to be scrapped.

December 23, 2016: Received notification that the vessel arrived at Brownsville, TX.
Changed vessel status to “scrapped” in the Coast Guard’s MISLE database.

I would agree that the lawyers,MBAs, and accountants in senior management at most companies know nothing about the condition of their ships or ship operation. From senior management’s point of view, they are in the business of selling a “logistics service.” The ships are merely incidental to the logistics business.

But Tote must have had some Port engineers and Port captains that were aware of the obvious physical defects that the USCG Seattle observed.

You make a good point, the USCG Seattle probably would not have noticed the defects in El Junkie, if it were not the sistership of EL Faro which had just sank, and owned by the same company. Instead of the usual soft glance, the USCG gave El Junkie a hard look.

You’re probably right that this had more to do with USCG CYA , rather than a renewed commitment to maritime safety in general.


Thank you for clarifying things regarding the El Yunque. Quite a story which shows that the El Yunque and presumably also the El Faro, were in real bad shape. Apart from the vents one could expect that also other ship parts were in poor condition.

Really have to wonder what condition the El Morro was in when Tote decided to scrapped her in 2014.

I don’t know, remember when we first got the news that the El Faro had been lost, we could not understand how it could have happened. Some of the posters that participated in those threads sailed on those ships. The possibility of propulsion loss by lost of lube oil suction was mentioned but nobody brought up those cargo vents.

Anyone that has sailed, is aware of the attitude of most companies when it comes to shipyard and getting repairs done. I know that as CE, I was told to be careful with what was said and told to make sure that the inspectors did not find certain things. Some of this I lived with (as most of us would have) but others I made a point to steer the inspectors to!

Back in the 70’s I remember inspecting the cargo tanks on an Oil Barge with the CG. The CG Inspector ordered the tank sealed up with us inside to block and light. Once it was sealed up it looked like we were looking up into the night sky as all of the holes in the deck showed themselves. We climbed out and he ordered the deck cleared and everything moved. The company had the crew place lines and anything else over any suspect areas to hide the damage. The CG Inspector said he gave them a 10 for trying but made them do the repairs.

Thinking back to all of the Yard Periods that I have been through, I can remember many times where things were found and reported by crew but were hidden from either ABS or the CG. The excuse was always, we don’t have the money or time for this now BUT we will fix it at a later date.

With my last company, I was called into the office and told to stop writing repair items up as safety items or I might be let go. My reason for doing it was anything written up as Safety had to be repaired and not put off. Did I abuse it maybe but all I was doing was using the SMS system against them which they hated.

I was one of the few that actually read the SMS books on a regular basis. They used to love quoting the SMS when it was in their favor but hated it when the “Crews” would use it to show that the office and support staff weren’t doing their jobs.

Now a days with jobs being tight, it puts the crews in a bad spot. Do you push for repairs that might lead to a layup or scrapping or cross your fingers that nothing bad will happen and let it slide??? This is one of the reasons that I’m glad that I’m retired and don’t have to make those decisions.


This is from the CG MBI report:

I was very surprised when I saw this diagram how little righting arm the ship had.

I’ve made a couple passes at this and am not sure what is being said.
Intact and Damage Stability
EL FARO met applicable intact and damage stability requirements for the accident voyage
that departed Jacksonville on September 29, 2015. However the vessel was operated very close to the maximum load line draft, with minimal stability margin beyond its required metacentric height (GM). 77 EL FARO’s past conversions reduced its ballasting options, leaving little flexibility for improving stability at sea if necessary due to heavy weather or flooding.

At the time of the casualty, EL FARO was subject to intact stability requirements of 46 CFR
§ 170.170 (the GM “weather” criteria); and EL FARO met those requirements on the accident
voyage. EL FARO departed Jacksonville on the accident voyage with a GM approximately 0.64 feet greater than the minimum required GM. 78 The difference between the minimum required GM and the calculated GM for a vessel is referred to as the vessel’s GM margin. EL FARO’s GM margin was reduced to approximately 0.3 feet at the time the vessel lost propulsion on the morning of October 1, 2015. 79

As operated and loaded for the accident voyage, EL FARO’s stability would not have met the
stability criteria for a new cargo ship, as the vessel did not meet the righting arm criteria for new cargo ships based on limited available area (righting energy) above 30 degrees of heel and an insufficient angle of maximum righting arm (see Figure A from Figure Sheet). 80 In order to fully meet the intact stability criteria of Part A of the 2008 IS Code at the full load draft, the minimum required GM would be approximately 6.8 feet, which is 2.5 feet greater than the GM of the actual departure loading condition of the accident voyage. However, paragraph 2.2.3 of Part A of the 2008 IS Code provides that “alternate criteria based on an equivalent level of safety may be applied subject to the approval of the administration” if obtaining the required 25 degree b angle for maximum righting arm is “not practicable.” Thus, the Coast Guard can permit a relaxation of the limiting criteria for minimum angle of maximum righting arm (25 degrees) on a case-by-case basis for new cargo ships.

When EL FARO underwent its major conversion in 1992-1993, it was required to meet the
probabilistic damage stability standard of SOLAS 1990. During the 1992-1993 conversion, ABS completed, reviewed, and approved a SOLAS probabilistic damage stability analyses, 81 and it was confirmed that the limiting stability criteria for EL FARO was the intact GM criteria (46 CFR § 170.170) for all loading conditions. Based on MBI testimony, Herbert Engineering
Corporation (HEC), did not complete a new damage stability analysis to confirm that the limiting criteria would remain the intact stability criteria for all loading conditions 82 after the 2005-2006 conversion, and ABS had no records of a damage stability analysis being completed. 83 A damage stability analysis should have been conducted because the 2005-2006 LO/LO conversion increased EL FARO’s load line draft by more than 2 feet. The increased load line draft invalidated the previous damage stability analysis completed in 1993.

During MBI testimony, 84 the ABS Chief Engineer for Statutes submitted results of an ABS
SOLAS probabilistic damage stability analysis performed on EL FARO in May 2016, 85 where he
applied the damage stability standards of SOLAS 1990, which would have been applicable in
2005-2006. This analysis determined that GM values of approximately 2.9 feet at both the load line and partial load line drafts (30.11 and 26.02 feet), would attain the required subdivision index of 0.60. MSC completed a similar analysis and obtained similar results, but with a slightly higher minimum GM value of 3.3 feet. 86 This suggests that for most EL FARO load conditions
with two or more tiers of containers loaded, the limiting stability criteria would be the intact
stability criteria (46 CFR § 170.170), but for some load conditions with less than two tiers of
containers loaded, the limiting stability criteria could be the damage stability criteria. The
potential for damage stability to be the limiting criteria was not reflected on the minimum
required GM curves in EL FARO’s T&S Booklet. 87 However, for the full load departure
condition of the accident voyage, since the majority of container stacks were three tiers high, the limiting stability criteria was the intact stability criteria (46 CFR § 170.170), which was properly reflected in EL FARO’s T&S Booklet and incorporated in its CargoMax stability software.

agree that these righting arm curves are terribly minimal and shows how the regulators who are “supposed” to protect the lives of mariners are failing at their job. EL FARO was a capsizing just waiting to happen but Davidson should have been aware of that and with that knowledge should have stayed very far away from Joachim. Again, imo the ship would have survived if is had only been only 20miles further east which certainly the master could have explained to management that he had to keep a buffer between the ship and the storm. Even if management couldn’t accept that excuse, he had his own life to protect as well as all the others aboard! More and more the finger points to Davidson being oblivious to danger and drove EL FARO headlong into it and ultimately to its oblivion!


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My memory may let me down here but I think there was a fourth mate who was responsible for operating the bow door and he/she had been let go and the task was assigned to the assistant bosun.
The masters had requested that indicator lights be fitted on the bridge to confirm the closure of the door when the extra mate left but this had been ignored by management.
There were three captains working shifts and the senior one was arrested in his home workshop while turning a salad bowl on a wood lathe.

We usually never agree but this is an exception.

Absolutely. It could mean the difference between life and death.

Excellent thread. Lots to think about and chew on, especially for those of us still working.

There are three major elements to this loss. Crew errors, ship not seaworthy and a failure of the SMS. I think there is something to be gained from digging into each element.

If facts are raised or points discussed that are contrary to anyone’s preferred narrative so be it.

"His critique echoed Coast Guard Capt. Domenic Calicchio’s famous 1984 report on the Marine Electric disaster, the last American marine casualty of similar magnitude. "

You know why there is an echo? Because there is nothing between then and now but empty space.

“Call to action” my ass … all I hear is a can being kicked down the road - again.

How many times have government agencies, military, regulators, operators and all of those who should have, could have, and knew they were supposed to prevent easily foreseen disasters made the hollow claim that “this must never happen again”?


Well, as we all said, nothing will change and all they are doing is placing the blame on the “Other” guy!

In many industries, the insurance companies do the real oversight of the owners. Yes, there are regulations, but often the insurance companies have smarter and better inspectors and demand above and beyond the minimum regulations.

Of the top of my head, pilots flying airplanes may be legal per the FAA rules, but the insurance company is going to dictate minimum hours, training, etc.

Shore side pressure vessels and rotating machinery. Many states have an inspection program and requirements, but the insurance companies often go way above these regulations in their demands.

Government has failed, and will always continue to fail. Why do people here act surprised?

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Well it was a surprise. It was the way everything worked against them.

I once made a distance/speed/time mistake and got an ETA to the pilot station wrong by almost exactly an hour. However we had also gotten the time zone wrong. Could have been a total two hour error but the errors cancelled and we arrived at the p/stn right on time.

On the other hand on the El Faro all errors compounded. The low righting arm, the lack of watertight integrity, the errors in the forecast, none surprising alone, but what are the chances everything would align against?

The first two are related to profits, the low righting arm is a result of an increase in cargo capacity and the loss watertight integrity is a result of cost cutting.

The one thing that surprised me the most was lack of situational awareness with regards to the location of the center.

I ask this question: how many times a year do ships find themselves in weather like the El Faro encountered?

Include any reason: incompetence, caught by surprise, planned routing…

I think all agree the route of the ship was the beginning of the tragedy. But, how many captains make the same errors in routing each year but their ship doesn’t sink?

My point is mistakes happen. Folks are going to misjudge weather. Was the weather that much worse than what you old salts have seen in the North Atlantic or Alaska?

This capt and crew were making decisions based on the assumption their ship was inspected and seaworthy. When I step on the brake pedal in my car, I expect the brakes to work and slow me down. If I rear end somebody at a red light due to brake failure, you can’t tell me “gee, you should’ve started slowing down 2 miles before the intersection.”

I wonder if things might change if the Classification Society’s were employed by the insurance companies and the shipowner dealt only with the insurer. Every one needs the business but in some cases deficiencies are overlooked to keep the customer (shipowner) sweet.
An AHTS in Vietnam was registered in Belize. There was no flag state regulations. At the time a Canadian judge could not extradite a fraudster from Belize to the USA because he couldn’t find any law pertaining to Belize.
If you stood in the Forepeak tank you could damm near see the afterpeaks which didn’t worry the Classification Society. The entire fleet was known as “Reg’s rent-a-wrecks.”

When you drive a 50 year old car, you know that you need to do a good inspection once in awhile and drive conservatively. You should know better that to hot rod it.

You also know that if your friendly local inspection station isn’t really doing its job (they put a new sticker on almost anything — just like the USCG and ABS) , then you have to do your own inspection of the basics like brakes (or water tight enclosures).

You can’t just assume that you can hot rod your 50 year old car and it will perform like a new one.


A better analogy would be if:

you were driving 80 mph in a 50 mph zone - Even new ships should avoid hurricanes. excess risk.

You were driving the wrong way down a one-way street - El Faro drove into the dangerous semi-circle

And your brakes failed on your 50 year old beater. Old ship, lack of watertight integrity.

The excess speed and the wrong way driving turned the result of a brake failure from fender bender to deadly fireball head-on collision.