A ship captain's unwillingness to listen to his crew's suggestions to change course from the path of a raging hurricane. A weak corporate safety culture that left crewmembers ill-prepared to deal with heavy weather. An old ship with outdated lifeboats, open to the elements.
All these factors contributed to the sinking of the El Faro in the fury of Hurricane Joaquin on Oct. 1, 2015, which killed all 33 people on board, the National Transportation Safety Board announced on Tuesday. The report concludes a 2-year investigation into the worst U.S. maritime disaster in modern history.
The NTSB issued 53 safety recommendations along with its findings, which investigators hope will be adopted by the industry, maritime safety inspectors and weather forecasters to make the seas safer for future generations.
"I hope that this tragedy at sea can serve as a lighthouse to guide the safety of marine transportation," said Robert Sumwalt, the board's chairman.
The El Faro, which means lighthouse in Spanish, sank between Jacksonville and San Juan, Puerto Rico after losing engine power in the Category 3 storm. The NTSB retrieved the ship's voyage data recorder, or "black box," from the sea floor near the Bahamas, 15,000-feet (4,570 meters) under the surface. The device held 26 hours of data, including audio of conversations on the ship's bridge as the frantic crew struggled to save the ship and themselves.
While the board found no fault with El Faro Capt. Michael Davidson's decision to leave port in Jacksonville, they did blame his reliance on an emailed weather forecasting system that contained hours-old data, rather than online updates from the National Hurricane Center. Investigators believe, based on his decisions and recorded comments, that he wasn't aware of the delay in the data, and that instead of skirting the storm, he sent the El Faro on a collision course with the hurricane.
"Although up-to-date weather information was available on the ship, the El Faro captain did not use the most current weather information for decision-making," NTSB investigator Mike Kucharski said at the meeting, held in Washington, D.C. "The captain did not take sufficient action to avoid Hurricane Joaquin, thereby putting El Faro and its crew in peril."
The board also criticized the "weak safety culture" of ship owner TOTE Maritime, Inc., including the lack of employee training for dealing with heavy weather situations and flooding. A hatch had been left open, allowing water from the roiling sea to flood an interior hold; this led to the ship tilting, disrupting the flow of oil to the engines. Once the freighter lost engine power, it was at the mercy of battering swells.
Also, the ship's wind gauge, called an anemometer, was broken and the 40-year-old freighter's open-top lifeboats would not have protected the crew, even if they had been able to launch them. The El Faro was legally allowed to carry lifeboats that expose people to the elements — just like the lifeboats on the Titanic and the Lusitania — due to safety-rule exemptions for older ships.
Whether the crew could have survived Joaquin's punishing winds and high seas had the El Faro been equipped with the closed-top lifeboats used by newer ships is unknown, but NTSB safety investigator Jon Furukawa said it could have helped crewmembers fighting for their lives .
"We believe that would've been the best method of departing the vessel under these conditions. It is still challenging, and we don't know if they would've survived," Furukawa said. "But enclosed lifeboats are the current standard and the El Faro did not have the current standard."
The board is not only recommending closed-top boats for all merchant ships, but also that the entire industry require crewmembers to carry personal locator beacons to better locate them during marine emergencies.
The El Faro had an older emergency position-indicating radio beacon, or EPIRB, which did not transmit global position system coordinates, and that made locating the ship more difficult for search-and-rescue crews. Given the heavy weather, rescuers probably couldn't have reached the ship any sooner, but the board believes the new requirement would help in future sea accidents.
The NTSB's draft recommendations are not law, but are used to guide industry changes or updates to existing safety procedures overseen by the U.S. Coast Guard and so-called "classification societies" like the American Bureau of Shipping, which conducts a large percentage of marine inspections on the Guard's behalf. The recommendations also can be used by Congress to create new laws meant to improve safety.
Larry Brennan, a maritime law professor at Fordham Law School and retired U.S. Navy captain, said the NTSB's recommendations highlighted major safety problems in the entire industry, including the Coast Guard and classification societies that are in charge of inspecting vessels for safety.
"El Faro was a worn, aged ship which succumbed to heavy weather in large part because of multiple unseaworthy conditions, poor leadership and bad decisions by the captain, American Bureau of Shipping, the owners as well as inadequate surveys and inspections by the U.S. Coast Guard," Brennan said.