Coast Guard Comandant Issues Final Review Of El Faro Investigation

Dec 21, 2017

The Coast Guard’s highest ranking officer concurs with many of the marine safety recommendations issued, including phasing out open lifeboats across the board, following six weeks of hearings into why the cargo ship El Faro drifted into a hurricane and sank somewhere in the Caribbean two years ago. 

Guard Commandant Admiral Paul F. Zukunft began his final review of the Marine Board of Investigation report by extending his condolences to the families of the 33 mariners who perished.  

“The Coast Guard will take appropriate action on all that we have learned from this investigation,” he wrote.   

The report, which detailed almost 40 recommendations, was the culmination of one of the most thorough investigations the Coast Guard, along with partners at the National Transportation Safety Board, has ever compiled.  

Though the board issued the recommendations after an exhaustive investigation, the Commandant has the final say in how many of them are adopted — Zukunft can fully concur, agree with caveats or disagree completely with the MBI’s findings.  

The commandant concurred with his investigators that “while many factors contributed to this marine casualty, by far the most prominent was the Master’s decision to sail the ship in close proximity to a Category 3 hurricane.”  

According to Zukunft, Captain Michael Davidson had “multiple opportunities to take alternate, safer routes as the storm approached” and that ultimately “prudent mariners avoid” such dangerous weather conditions.  

That being said, the commandant still heaped a healthy amount of blame on the ship’s owner and operator TOTE Services for “numerous failures” to “properly fulfill its obligations under the International Safety Management Code.”  

Ship Safety Equipment And Software  

The commandant concurred with what some marine experts have said would have ensured the survival of the crew — a requirement for ships to carry enclosed, self-propelled lifeboats. El Faro was equipped with open lifeboats that investigators concluded crew members were unable to launch during the ship’s sinking.  

After the sinking of the Marine Electric during the 1980s, the Coast Guard recommended retrofitting existing ships with the newer, safer lifeboats and a law was passed implementing the requirement. However, the law contained a provision exempting ships built before it was passed — grandfathering in older vessels like El Faro.  

The commandant wrote he “supports proposals from vessel owners and operators or legislation to accomplish this” and that in the meantime, “the Coast Guard will initiate a concentrated inspection campaign to ensure that the lifeboats remain in serviceable condition.”  

“The inspection will include the launching, maneuvering and recovery of open lifeboats and the review of related SMS procedures,” Zukunft wrote.  

But the commandant stopped short of directly recommending Congress amend the lifeboat regulation. Maritime attorney Rod Sullivan, who has represented some El Faro family members, said he would have liked to see a stronger recommendation from Zukunft.

“I firmly believe that the single greatest failing in this case was not the sinking of the ship itself,  but the fact that no one survived.  Ships sink all the time.  What is unusual is for a ship to sink and for all hands to be lost,” Sullivan wrote in an email.

The commandant also concurred with recommendations that ships be equipped with modern flood alarms, closed circuit television cameras in stowage areas, that mariners have their own personal locator beacons and the review and approval of cargo loading and stability software. During the hearings, investigators detailed how the ship may have been improperly loaded partially because the crew was relying on flawed loading software.   

Ship Inspections, Search And Rescue  

A major sticking point on the regulatory end of the MBI’s investigation was whether or not the Alternate Compliance Program, which essentially outsources many ship safety inspections to private entities like the American Bureau of Shipping, adequately reviews vessels.  

A Coast Guard report detailed during one of the MBI’s hearings and a subsequent NTSB investigation both found the inspection program missed a large number of deficiencies and the Coast Guard recommended the creation of a new training program for inspectors. The commandant concurred.  

“The Coast Guard will establish an Advanced Journeyman Inspector course to provide advanced training on alternate inspection programs, third party oversight, auditing principles and other advanced and contemporary topics,” he wrote. “To further improve knowledge, communication, and coordination between Coast Guard marine inspectors and third parties, the course will be made available to third party representatives on a space available basis.”  

The commandant also agreed with a recommendation that the program be more transparent by the Coast Guard publishing an annual report of vessel compliance that would include the identities of ship inspectors and which vessels had failures.  

Zukunft also concurred with a recommendation that he review “current intact and damage stability standards to improve vessel survivability in extreme wind and sea conditions.”  

The commandant didn’t partially or fully agree with every recommendation, however. Zukunft disagreed with MBI recommending the Coast Guard track all ships in real-time similar to the Federal Aviation Authority. He also didn’t concur with another recommendation that Coast Guard search and rescue teams be required to collect DNA samples of perished mariners for identification.  

Zukunft said that requirement would just further imperil Coast Guard rescuers during extreme weather conditions. Meanwhile, he concurred with a recommendation for a review of ship tracking programming that the Coast Guard uses in its search and rescue efforts.  

Company Liability  

Zukunft also concurred that enforcement action should be taken against TOTE Services for a number of failures, including not complying with emergency procedures, not adhering to work-rest requirements for crew members, and a failure to notify the Coast Guard or the American Bureau of Shipping of repairs to El Faro’s main propulsion boiler superheating piping.  

“The investigation has determined that there is evidence that TSI [TOTE Services Inc.] may have committed multiple violations of law or regulation. As such, the alleged violations identified in this recommendation will be referred to the Officer in Charge, Marine Inspections, Jacksonville, for investigation and enforcement action, as appropriate,” he wrote.  

Coast Guard Captain and MBI chairman Jason Neubauer said that he expects the company to be fined.  

“I don’t have the exact amount, but I think it’s in the neighborhood of $80,000,” he said.  

In a statement following the release of the commandant's review, TOTE spokesman Darrell Wilson wrote "although the report finds that responsibility for the accident is sh ared among a number of parties, the El Faro and her crew were lost on our watch. For this we will be eternally sorry."

Wilson goes on to say the company will be assessing the Coast Guard's recommendations and that the company "supports changes that enhance safety for seafarers. Safety has always been a central focus of our company and will remain so in the future."

The company has not yet responded to WJCT's request for comment on possible fines or other civil action. 

The commandant’s review of the MBI report follows a final report by the NTSB and precedes possible legislation to be filed by Sen. Bill Nelson (D-Florida).   

Reporter Ryan Benk can be reached at rbenk@wjct.org, 904-358-6319 or on Twitter @RyanMichaelBenk