Ahead of NTSB meeting on El Faro sinking, ship owner highlights human error

In some of the final input into a two-year investigation, owners of the sunken cargo ship El Faro underscore to federal officials the role mistakes by the ship’s captain and crew may have played in its sinking and the deaths of 33 mariners.

Reports from Tote, Inc. were added last month to a nearly 21,000-page docket the National Transportation Safety Board maintains for its investigation of the ship’s loss during Hurricane Joaquin as it sailed from Jacksonville to Puerto Rico.

They’re among the last filings expected to be added before NTSB members meet Tuesday in Washington to discuss the cause of the Oct. 1, 2015, sinking and recommend safety policies to prevent future disasters.

Friday’s announcement of that meeting said the “major safety issues” associated with the incident include not only the actions of the captain, but the currency of the weather information he used, management of the ship’s bridge team, company oversight, damage-control plans and the suitability of the ship’s survival craft.

In its filings, Tote encouraged NTSB staff to find El Faro was “seaworthy and fit for its intended voyage” but that its captain, Michael Davidson, had “a loss of situational awareness” that increased danger from the hurricane. Elsewhere, an engineering expert hired by Tote said the ship might well have survived the storm if a hatch that wasn’t secured had been completely sealed to keep water out.

“In retrospect, it appears from the evidence developed in the investigation that the master [captain] had a mistaken perception of Joaquin’s position/track,” reads a report to NTSB from Lee Peterson, director of marine services and safety at Tote Services, the arm of Tote that operated El Faro.

“… It appears more likely than not that the vessel would have avoided the worst effects of Joaquin had it made the timely diversion to the south, as proposed by the second mate.”

The second mate, Danielle Randolph, phoned Davidson about 1:30 a.m. on Oct. 1 and suggested changing the ship’s southeasterly course to due south through a shallow passage between islands in the Bahamas. Davidson told Randolph to stay with the original plan, and the ship sank about six hours later in 15,000 feet of water.

It’s not clear how closely Tote’s assessment of the sinking matches that of NTSB investigators, whose final report and recommendations won’t be released until board members vote on them. Groups or companies taking part in investigations, such as Tote, are also barred from commenting before then.

Tuesday’s meeting could last several hours, said Peter Knudson, an NTSB spokesman. He said board recommendations can vary from narrow findings that affect a single business to policies changing whole industries.

Tote’s description of the sinking highlights a handful of problems that could be lethally magnified by the punishment of a Category 3 hurricane, Joaquin’s strength when El Faro sank.

Davidson “was widely regarded as a qualified, competent, well-trained, safety-conscious master,” the report says, using the mariners’ term for captain. It adds that the choice to leave Jacksonville two days before the sinking had been reasonable, as had the route, based on weather forecasts at the time.

But forecasting of the storm’s path was sometimes wrong and changed, and the report says Davidson seemed to rely on a weather-tracking system El Faro had that was often outdated. National Hurricane Center advisories were available on El Faro too, the report says, but the Bon Voyage System weather tracker that Davidson repeatedly downloaded on El Faro was based on the previous advisory – from about six hours earlier.

“It is not clear that the master fully comprehended this,” says the report. It says the most recent Bon Voyage information Davidson had when he rejected Randolph’s course change would have been based on a hurricane advisory from 11 a.m. the day before. Because he was using old information and wasn’t experiencing terrible winds or waves yet, the report say says that Davidson, who had sailed tumultuous seas off the Alaskan coast and was confident in bad weather, may not have realized how much trouble was closing in.

Once Joaquin was really battering El Faro, Tote says, another human error probably let in the first gallons of a torrent of floodwater that eventually consumed the ship.

Seawater washing over a deck that was designed to be watertight accumulated against a bulkhead, or wall, and reached a foot-tall hatch that was supposed to be sealed but wasn’t. The hatch, called a scuttle, led to a cargo hold beneath that deck that could have begun filing with seawater as early as 3 a.m., the report says. By 5:30 a.m., close to 16,000 gallons (weighing more than 13o,000 pounds) could have flowed into that hold near the middle of the ship, building up on the hold’s right side and pushing the ship to lean, or list, that way.

Before 6 a.m., the open hatch had been discovered and within minutes Davidson had turned El Faro so water would flow to the left side and a crew member could reach the hatch and close it – but the worst problems were just starting.

Seawater on the deck above the cargo hold was reaching higher and higher, and an analysis from an engineering professor Tote hired says it soon flowed below decks harder and faster. When El Faro leaned to the side during big waves, says the report from Charles Munsch of the State University of New York’s Maritime College, the water reached openings in ventilation shafts and raced down to the hold 10 times as fast as it had through the hatch.

Worse, reversing the ship’s list seemed to lead directly to El Faro losing propulsion, apparently because oil in a lube system for the ship’s engine shifted like the water and couldn’t be pulled into the machinery. The ship’s engine stopped about 6:15 a.m., and engineers worked about 45 minutes to restart it before Davidson phoned Tote to report a marine emergency.

Without propulsion, the 790-foot-long ship could be pushed broadside into the worst waves, and more and more water flowed below the once-watertight deck. By 7:30 a.m., about the time El Faro sank, Munsch’s report estimates 1.2 million pounds of water had flowed into one cargo hold, and the excess had sloshed into the next hold.

While problems compounded upon each other, Munsch describes the open hatch as the first link in a fatal chain.

“In my opinion, if the scuttle was secured, it is likely the SS El Faro would have survived this storm,” he writes.

Tote’s report says the chief mate, Steven Shultz, was responsible for ensuring hatches and watertight doors were secure, but a transcript of Davidson’s emergency phone call shows the captain didn’t know how the hatch ended up open.

“A scuttle was blown open,” Davidson said, “… by the force of the water perhaps — no one knows. Can’t tell.”


While Tote’s report mentions the potential that individuals’ mistakes to could have dire consequences, it says nothing suggesting the company carried responsibility.

Tote Services “had (and has) a strong safety culture. The same strong safety culture carried over to the vessels in its management, including the El Faro,” the report says.

It adds later: “The evidence gathered during the investigation indicates the master, mates, and crew, understood that no operational commitments of the trade, such as the schedule, justified jeopardizing the safety of the crew, the vessel, or the cargo. To the contrary, there was consistent evidence and testimony that safety was of paramount importance.”

Those points push back against the assessment a Coast Guard board released in October that said Tote “did not ensure the safety of marine operations and failed to provide shore side nautical operations supports.”

When the Coast Guard listed factors contributing to El Faro traveling too near the hurricane, the agency mentioned Tote in the first six entries. Those included assertions that Tote hadn’t provided tools for accurate weather observations and didn’t provide adequate support and oversight to El Faro’s crew.

NTSB’s board will talk through its own findings in a meeting that’s scheduled to be carried online Tuesday. The meeting is public, but only NTSB members and staff will be allowed to speak.

Steve Patterson: (904) 359-4263




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