Lessons Learned - July 2018

Safety First

It is said among mariners that yes the captain has the authority to refuse orders that he deems to be unsafe, but probably only once.


The El Faro

El Faro departed Jacksonville, FL. the morning of September 29, 2015 bound for Puerto Rico with 391 shipping containers and 294 cars. The El Faro made this trip weekly and if she was delayed the store shelves in Puerto Rico would be bare and the local economy would suffer.

By now most of us have either read about or heard the news stories about the unfortunate loss of the 791-foot, mixed cargo ship, El Faro, and her crew of 33 on October 1, 2015 when she sailed directly into the eye of Hurricane Joaquin, a category 3 hurricane with sustained winds over 80 knots and seas up to 40-feet. The El Faro was one of two ships owned by TOTE Maritime that moved cargo between Jacksonville, FL and San Juan, Puerto Rico on weekly runs. The other is El Faro’s sister ship the El Yunque. The El Faro was a U.S. flagged roll-on/roll-off and lift-on/lift-off cargo ship built in November 1975 at Sun Shipbuilding and crewed by U.S. Merchant Mariners. El Faro’s U.S. construction, U.S. ownership and U.S. merchant mariner crew allowed her to carry cargo between U.S. ports under the Jones Act.

At 0730 on October 1st the captain last reported the ship was taking on water, listing at 15 degrees and had lost propulsion. The El Faro had suffered loss of propulsion at sea before and her boilers were scheduled to be repaired at her next dry docking, just after this one last run. A known issue with this particular power plant design was that if the ship listed more than 15 degrees, the lubricating oil would pool to one side of the sump, oil pressure would fall, and the engine would stop.

One minute later he ordered the crew to launch the life boats and abandon ship.


Fishing Vessel Kupreanof

The Kupreanof was a steel hull 73 foot fish tender built in 1975. Her home port was Petersburg, AK. Tenders meet at sea with fishing boats having reached full capacity, unload the fish and then transport the catch to the nearest fish processing plant. According to crewmembers, the vessel had primarily worked the inside passage in southeast Alaska prior to the accident. The transit to Bristol Bay was the vessel’s first voyage in the open ocean in over two decades. She was crewed by an unlicensed captain, an engineer and two deckhands. The captain had worked in the fishing and yachting industries for about 40 years with about 10 years of experience on tenders. He was hired on the Kupreanof three weeks before the accident voyage and had only begun significant work on the vessel 10 days prior to departure. The other three crewmembers joined the tender between June 1 and June 2. None of the crewmembers had any previous experience on the vessel.

A September 2014 survey reported that the Kupreanof was “immaculately kept, well maintained, in excellent condition and fully equipped for her intended service.” The survey also noted that the hull of the vessel had been ultrasonically tested in 2012 and deemed to be in satisfactory condition. By May 2015, the vessel was under new ownership and the captain stated that it was in “a little bit rougher shape than I knew about.” The condition did not concern the captain enough, however, to stop him from taking the vessel out to sea.

At About 0500 on June 9, the uninspected fishing vessel departed Juneau, Alaska, en route to Bristol Bay, Alaska via the Inside Passage and the Gulf of Alaska. According to crewmembers, the transit to Bristol Bay was to be the vessel’s first voyage in the open ocean in over two decades. About 1500, as the vessel transited the Inside Passage, the captain checked the weather forecast but was not concerned with the conditions. The National Weather Service forecast issued at 0400 that morning predicted winds increasing to 30 knots and seas building to 11-feet through the evening. A small craft advisory was in effect through the night.

Just an hour later, before reaching the open waters of the Gulf of Alaska, the captain anchored the vessel to test the anchoring equipment, check the lashings of the gear on deck and review safety equipment and procedures with the crewmembers. During the safety review, the captain instructed the three crewmembers on donning survival suits, launching the life raft and locating and operating the Emergency Position Indicating Radio Beacon (EPIRB). The captain also assigned each crewmember specific responsibilities in the event of an emergency. About 1800, the vessel resumed its voyage.

Three hours later, after the vessel entered the Gulf of Alaska, the weather conditions worsened as seas increased to 15- to 20-feet. Just prior to midnight, the captain checked the weather forecast again. The latest forecast, which had been issued at 1600 (an hour after the captain had last checked the forecast), included a gale warning with 35 knot winds and 10-foot seas predicted through the night. The captain said the report surprised him based on what he had seen in the earlier report.

At 0300 the captain woke the engineer to relieve him at the helm. Before heading to his cabin for rest the captain went to the vessel’s aft deck to secure a large hose that had come loose. At about 0330, the captain noticed that the stern was “sitting down” more than normal and not shedding water as expected. Soon after he noted that the vessel had taken on a port list. In an attempt to resolve the list the captain checked the engine room for water accumulation and pumped out the bilges in the space, along with the shaft alley. He then began pumping out the lazarette, the aft-most space on the vessel. A single pump was used to remove water with a valve manifold in the engine room controlling which space was being pumped; this is a common configuration for bilge dewatering. The captain did not find a significant amount of water in the engine room spaces, but he could not check the lazarette because equipment was stowed atop the access hatch. Both the main fish hold and the aft bait hold were completely filled with water before the Kupreanof left Petersburg. The captain stated that he did not attempt to pump out the water in these spaces, fearing that free surface effect in the holds would make the vessel less stable. Both the captain and the engineer were aware that the vessel had capsized several years before when the holds had not been completely filled.

After unsuccessfully attempting to resolve the port list, the captain woke the other crewmembers to alert them of the problem and directed them to move to the upper decks with their survival suits. The list and aft trim on the vessel progressively worsened with the stern continuing to sink further into the sea and waves breaking over the transom. At 0342, the captain made a Mayday distress call to the Coast Guard and Coast Guard Sector Juneau launched rescue helicopters to assist the sinking vessel. After all attempts to correct the list had failed, the crew donned their immersion suits, deployed the life raft, and moved to the bow for safety while they waited for the Coast Guard to arrive.

A helicopter arrived on scene about 0510 and the crew moved to the aft deck, entered the water and boarded the life raft. A Coast Guard rescue swimmer assisted each crewmember into the helicopter’s rescue basket where they were hoisted one by one into the aircraft. The last crewmember was rescued from the water about 0540 as the vessel sank stern first. Crewmembers stated that none of the vessel’s bilge alarms sounded prior to abandoning the vessel. The captain told investigators that he had tested all bilge alarms prior to getting under way, with the exception of the lazarette. He could not test the lazarette alarm because the access was blocked by equipment on deck. The captain stated that he did not know what caused the vessel to sink, since he was unable to determine the source or location of the flooding. He believed a crack might have developed on the stern deck that led to flooding of an aft compartment.


Lessons Learned

Every ship I have crewed on and every company that I have worked for all proclaim safety to be top priority and nearly all of them want to run a safe operation. There are many catchy sayings and signs painted all over the ships and you have seen them; “Safety First”, “Think Safety,” “xx Accident free days,” among others. TOTE Maritime and the captain of the El Faro were no different. Only this time just lip service to safety caught up with them. As the NTSB and USCG reports indicated, concern over schedule outweighed the concern of safety. For example, the captain charted a course that would pass around the then tropical storm and gambled that the storm would not increase to hurricane strength and would not change course. The company allowed the ship to depart on schedule despite the varying path and strength predictions from the National Weather Service. In other words, the experts did not know exactly where and when the storm would increase to a hurricane, but indications were that it would. The captain decided to take the usual 1265 nm straight line route from Jacksonville, FL, past the Bahamas, transit open ocean for two and half days, and then head southeast directly to San Juan. The safer route would have been to head south through the Florida Straits, east along Cuba and then thru the Old Bahamas channel to Puerto Rico keeping a string of islands between the storm and the ship. The problem was this route would add more than six hours to the voyage thus throwing TOTE’s schedule out of whack and burning $5,000 more fuel. Although the company had a paid weather service that sent updates to the ship every six hours, they did not opt for the upgraded service that provided hourly updates for any named storm. The company did provide a Qualified Individual ashore that the ship captain could call any time. At 0700 the captain used the ships emergency satellite phone to call TOTE’s designated QI ashore, the only person in charge of what was going on with the fleet. The call went to voicemail!

In the case of the El Faro, the U.S. Coast Guard investigator placed nearly all of the blame on the ship’s master, stating that he underestimated the strength of the storm and the ships ability to ride it out and did not take enough measures to evade the storm even though his crew raised concerns about its increasing strength and changing direction. The ship’s owner, TOTE Maritime, made several violations regarding crew rest time and work hours, had no dedicated safety officer to oversee the ship and allowed the ship to use outdated open lifeboats similar to what was used on the Titanic.

On October 2, 2015 the 40 year old ship was declared missing and an extensive search operation was launched by the U.S. Coast Guard, the U.S. Air Force, the U.S. Navy and the Air National Guard. A damaged, empty lifeboat and some debris were recovered and an unidentified body was spotted but not recovered. On October 7, 2015, the search and rescue operation was called off after having searched more than 180,000 square miles of ocean. On October 19, 2015, the U.S. Navy sent the USNS Apache to conduct an underwater search for the El Faro. On October 31, 2015, the Apache reported that she had spotted an intact ship sitting upright on the bottom. The next day a submersible sent images back that identified the wreck as the El Faro.

Access to high risk spaces and blocking access such as the lazarette on the Kupreanof, is a safety hazard. Without access the vessel crew cannot be sure of the condition of the space nor can they respond when emergencies like flooding affect those spaces. In this accident, access to the lazarette, the space containing the steering machinery and one or more hull penetrations, was obstructed which prevented crewmembers from determining if it was the source of flooding and if so addressing the hazard. All alarms and sensors should be tested on a regular basis to verify operation so that the crew has early warning of developing hazards.

As masters of our own vessels we have the same responsibility of safety for our crew and guests. Most significant shipping disasters are eventually determined to be “system accidents;” the result of a cascade of small errors, failures, and coincidences, absent any one of them, the disaster would not have occurred. Unfortunately the truth cannot be known in real time, only in hindsight. I had a situation many years back that involved the flooding of the lazarette with no alarms sounding.

We were on a coastal delivery from Canada to San Francisco relocating a 58-foot highly regarded sport fisher. Since the vessel carried a large amount of fuel, our planned first stop was Astoria, Oregon after a 24 hour run through the Straits of Juan de Fuca and the Washington coast. Generally the voyage going south is a better ride than going north, except when the following seas are quite large and make keeping a course more difficult. As we slowed for the overnight, the following seas were constantly breaking over the transom and pooping the cockpit. This is not unusual for this style of boat as they have a low freeboard suitable for fishing and the large cockpit of this boat had extra large scuppers allowing the water to drain from the cockpit quickly leaving the deck nearly dry before the next swell broke over the transom.

What we did not know until arriving the next morning at the fuel dock was the lazarette had flooded nearly completely and the stern was very low in the water. How could this occur? We had checked the operation of the bilge pumps and alarms prior to departing and felt confident that the systems worked as designed. Every few hours we would make an engine room check and the bilges were always dry. At the dock when the lazarette bilge pump was activated manually it came to life just as it did prior to our departure just 24 hours earlier and dutifully drained the lazarette in 10 minutes.

Thinking back, the lazarette did not have a high water alarm and we did not know at the time but the engine room and lazarette on this boat are separate sealed spaces. The bilge is closed and the bulkhead does not have a limber to allow water to flow between them. The only high water alarm was in the engine room. The switch that would automatically activate the lazarette pump was an electronic sensor type and not the more common, and more reliable, lever action float switch. It was not possible for us to test the automatic function of the pump; we could only activate it manually using the switch at the breaker panel. So the next concern was from where did the water come and how can we prevent it from continuing. Once the bilge was dry we could see that there was no more water intrusion. Thinking that it had to be from the following seas pooping the deck we took a water hose and started flooding the deck. In short order we found that the sealing gasket on the lazarette access hatch had failed allowing water to run from the deck into the lazarette almost unimpeded.

After fueling and breakfast ashore, we reported to the vessel owner our progress and the situation with the water intrusion. Imagine my surprise when he immediately admitted that he was aware of both issues, the non working float switch and the wasted hatch gasket and simply forgot to mention it to us prior to departure. His solution was to manually activate the pump every so often. Not willing to accept his “solution,” we made a trip to the local chandlery to purchase a good old fashion lever action float switch. We departed Astoria after the switch was installed and tested.

The best lessons we can learn are from others’ mistakes. These are much less costly to us in terms of treasury, ego and most importantly personal safety.

Time for me to sit back, enjoy a good glass of port, and light up a fine cigar while I plan for my next coastal voyage with the events of the El Faro and the FV Kupreanof fresh in my mind. Until next month, please keep those letters coming. Have a good story to tell, send me an email. patcarson@yachtsmanmagazine.com. I love a good story. H



The NTSB has authority to investigate and establish the probable cause of any major marine casualty or any marine casualty involving both public and nonpublic vessels under CFR49 section 1131. The NTSB does not assign fault or blame for a marine casualty; rather, as specified by NTSB regulation, investigations are fact-finding proceedings with no formal issues and no adverse parties and are not conducted for the purpose of determining the rights or liabilities of any person. Reading CFR49 Section 831.4. Assignment of fault or legal liability is not relevant to the NTSB’s statutory mission to improve transportation safety by conducting investigations and issuing safety recommendations. In addition, statutory language prohibits the admission into evidence or use of any part of an NTSB report related to an accident in a civil action for damages resulting from a matter mentioned in the report.

The U.S.C.G Marine investigators carry out investigation of commercial vessel causalities and reports of violations per CFR46 chapter 61, 63, and 77. The primary purpose of the U.S.C.G. investigation is to ascertain the cause or causes of the accident, causality, or personal behaviors, or if any violation of federal law has occurred, and to determine if remedial measures should be taken. The U.S.C.G. is authorized to enforce incidents involving vessel personnel, boating accidents, waterfront facility causalities, deepwater port causalities, marine pollution incidents, accidents involving Aids to Navigation, and accidents involving structures on the Outer Continental Shelf. The results of their investigations play a major role in changing current law, developing new law and regulations, and implementing new technologies.

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