JACKSONVILLE, Fla. – The U.S. Coast Guard on Sunday released the S.S. El Faro Marine Board of Investigation report.
The report identifies causal factors of the loss of the S.S. El Faro and 33 crew members, Coast Guard officials said. The report proposes safety recommendations for future actions to the commandant of the Coast Guard.
"The most important thing to remember is that 33 people lost their lives in this tragedy," said Capt. Jason Neubauer, chairman, El Faro Marine Board of Investigation, U.S. Coast Guard. "If adopted, we believe the safety recommendations in our report will improve safety of life at sea."
The report places TOTE, the captain and even the National Hurricane Center. Below are some of the findings:
- TOTE did not ensure the safety of marine operations and failed to provide shore side 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 Bon Voyage 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 trackline.
- 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 was 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 August 24, 2015.
El Faro sailed into the path of Hurricane Joaquin and sank two days after leaving Jacksonville en route to Puerto Rico. It was the deadliest maritime accident of its kind in more than 60 years.
Officials said Coast Guard standard procedure and 46 U.S. Code Chapter 63 require this type of report to be made for all marine casualties under Coast Guard authority.
The investigation was conducted by the U.S. Coast Guard with the full cooperation of the National Transportation Safety Board, officials said.
Click here to read the full report.
This article is courtesy of WJXT-TV.