Better hurricane alerts for mariners, mandatory personal locator beacons and modern, enclosed lifeboats on all U.S.-inspected oceangoing vessels are just a few of the detailed recommendations from the National Transportation Safety Board’s final report on the El Faro disaster.

The definitive, 282-page account of the Oct. 1, 2015 sinking and loss of all 33 persons on board the 40-year-old, 790’ ro/ro containership was released Wednesday by the NTSB.

There were no big surprises – NTSB commissioners who met in December to discuss their own findings largely echoed conclusions from the Coast Guard Marine Board of Inquiry issued in October 2017.

But their formal report is by far the most extensive review of the worst U.S. maritime accident in three decades, since the sinking of the bulk carrier Marine Electric off Virginia in a 1983 blizzard.

Like the Coast Guard, NTSB officials placed a lot of blame on El Faro captain Michael Davidson, for sticking to his vision of ducking south out of an early anticipated path for Hurricane Joaquin as it barreled across the El Faro’s normal route from Jacksonville, Fla., to San Juan, Puerto Rico.

A satellite image of Hurricane Joaquin on Oct. 1, 2015, showing the course of the El Faro. NTSB image.

A satellite image of Hurricane Joaquin on Oct. 1, 2015, showing the course of the El Faro. NTSB image.

Davidson held to that route despite warnings from his deck officers, who were seeing more updated weather information on the night of Sept. 30-Oct. 1. The report devotes nearly five pages to those exchanges, and possible explanations for Davidson’s decision-making.

That was also related to a failure of bridge resource management on the El Faro, the agency found. While the deck officers could have been more assertive in their objections to the voyage plan, Davidson should have been more open to their input, the report says.

This points to a larger problem in the maritime industry, compared to commercial aviation, where subordinate officers have more leeway for raising critical questions on the flight deck, NTSB officials suggested.

“The authority of the captain is traditionally treated as absolute, and mariners are accustomed to deferring to the captain’s decisions,” the report notes. “Although training in bridge (crew) resource management is required for mariners, it has not been as widely accepted or studied as in the aviation realm.”

One NTSB commissioner, Bella Dinh-Zarr, attached a dissenting opinion to the report, saying it was unrealistic to expect the deck officers should have done more to dissuade Davidson from his navigation choices.

El Faro operators Tote are assigned blame in the report, for failure to promote better bridge resource management and use of the company’s safety management system.

As did the Coast Guard’s own investigation, the NTSB probe documented problems with the Alternative Compliance Program and its use of classification societies to maintain surveys and inspections of U.S. flag vessels. The NTSB concurred with Coast Guard findings of shortfalls in its supervision of the program, and poor qualifications of its own inspectors.

Close examinations of a sister ship, El Yunque, found major corrosion in ventilation shafts that investigators suspected admitted down flooding into the El Faro cargo hold and engine spaces. Both of the 1970s steamships were to be transferred to Tote’s Northwest Pacific routes with the arrival of new liquefied natural gas fueled, Marlin-class containerships for the Puerto Rico trade.

Instead, corrosion problems on the El Yunque were so severe the company sold her for scrap in late 2016, the report notes.

Like the Coast Guard, the NTSB calls for requiring modern enclosed lifeboats on all U.S. flag oceangoing vessels. Regulations allowed ships built under rules in effect until the mid-1980s to retain old open lifeboats launched with gravity davits, like the pair carried on the El Faro.

In the U.S. bluewater fleet, 49 percent of the ships were delivered prior to 1986.

“Thus, roughly half of US-inspected oceangoing vessels are equipped with lifesaving appliances that have been considered insufficient for over 30 years,” the report says. Experts consulted by the investigators estimated equipping a ship like the El Faro with modern lifeboats would have been an upgrade of around $1 million, and may have given some of the crew a chance to survive.


Contributing Editor Kirk Moore was a reporter for the Asbury Park Press for over 30 years before joining WorkBoat in 2015. He wrote several award-winning stories on marine, environmental, coastal and military issues that helped drive federal and state government policy changes. He has also been an editor for WorkBoat’s sister publication, National Fisherman, for over 25 years. Moore was awarded the Online News Association 2011 Knight Award for Public Service for the “Barnegat Bay Under Stress,” 2010 series that led to the New Jersey state government’s restoration plan. He lives in West Creek, N.J.