NTSB releases final El Faro report

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.


About the author

Kirk Moore

Associate 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 a field editor for WorkBoat’s sister publication, National Fisherman, for almost 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.


  1. Avatar

    Dealing with a captain during or proceeding a hurricane really at the end of the day IT IS his decision. I was on a drilling rig and by company standards we should have started pulling riser 100+ hours before the hurricane Could possibly hit our area.
    We did not, and I confronted the captain and asked why were we NOT pulling riser and got back a totally unacceptable answer. Well he had been talking to town and they thought it might not hit us and that they were basically just doing b.s. Work down hole to have an EXCUSE of not pulling riser.
    I informed him that if anything happened it would be HIM and not the people on shore that would,be held responsible, and he was rolling the dice with the vessel and everyone onboard. And this was an assertive argument because people heard our voices even with the door to his office closed.
    We lucked out and the hurricane stayed a few hundred miles away and then turned into Florida. But if it would have turned on us we would have been sitting ducks with over 9000+ foot of riser hanging under us and still latched up to the bop. Imagine that and the weight once having done an emergency disconnect in 30 and 40 foot seas plus all the infastructure on the sea bed below us.
    So unless you are going to commit a multiney or just trhow him over board there is little you can do to an unwilling captain.
    And I was “just” the chief engineer onboard.

  2. Avatar

    Still lunatic thinking to travel within 67 miles of the eye of a hurricane. I don’t care what vessel you’re on. I’ve been on a tanker in 50’+ wave and 130+ knots. We were going Full Speed Ahead but ‘backwards’ as we climbed up/thru waves in a blender. The only reason we got stuck was the storm came up behind us and overpowered us. All it takes is one mechanical issue such as a hatch opening, the M/E going down, or structural damage in a storm like that and you’re dead. Not worth the risk. Get out of the way and never, ever play chicken with a hurricane of any size. If you do get caught in it, you’re at the mercy of mother nature and luck. You might make it and you might not.

  3. Avatar

    Astounding that the El Yunque is found to be in such a terrible condition that she winds up being scrapped by TOTE and yet ABS and TOTE get slaps on the wrist. Both those ships were floating crap heaps and should not have been trading at all, let alone being sent back into Alaskan trades.

  4. Avatar

    Seems like the captains’ reasons for either not waiting in port or not taking the inside route ought to be discovered. How much pressure was the captain under to meet a schedule? I bet there’s a lot we’re not being told.

  5. Avatar
    Captain Todd Nelson on

    When I first worked with that class of container ship, I was 24 years old. Now I am 64 years old. I was young and strong when those ships first sailed. But, like me, those ships are old and worn out. I was surprised when I saw on the news that, in this day and age, with all the electronic intelligence available, El Faro got anywhere near a hurricane with that much warning. I was shocked the ship even left the dock. This one is on the captain. Unfortunately, too many had to pay for his stupidity with their lives.

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    There are more and more companies where the Captain is just the top guy on the vessel. He takes his orders from Joe Boss, or he gets replaced. Unfortunately the job pays well enough that most Captains keep quiet about this trend. If a guy stands up for what he feels is right and just, and if shore-side has a different opinion he might very well find himself without a job.

    The bottom line for Captains today. “Shut up and drive the boat”!

    • Avatar

      It has been that way since the dawn of merchant vessels. Even 100s of years ago, there was the owner telling the captain to sail through the coming storm, “it’s ok, I have insurance on the vessel” attitude. Captain and company response to lower level employees today is a massive improvement compared to the history of merchant sailing.

      To be frank, I’d rather hear the company voice instead of the captain’s anyways, ESPECIALLY from most American companies. The smart ones are in the offices, not on the boats.

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