El Faro captain's mistakes compounded by problems that sank ship, investigators find

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The entire crew of the El Faro died when the cargo ship sunk in Hurricane Joaquin. An NTSB transcript reveals the captain dismissed a crew member's suggestion that they return to shore in the face of the storm. USA TODAY NETWORK

WASHINGTON — Federal accident investigators developed dozens of recommendations Tuesday for improving naval safety after citing a cascading series of problems that sank the cargo ship El Faro in a hurricane off the Bahamas two years ago.

The National Transportation Safety Board’s investigation built upon a Coast Guard investigation completed Oct. 1, which blamed Capt. Michael Davidson with misjudging the strength of Hurricane Joaquin and failing to avoid it.

All 33 crew members died when the vessel sank Oct. 1, 2015. The ship had been sailing its weekly run from Jacksonville, Fla., to San Juan, Puerto Rico.

The NTSB review cost $5.6 million and spanned 30,500 hours of investigative work for the worst U.S. maritime disaster in 30 years.

During the board hearing Tuesday, investigators described problems besides sailing into a hurricane that halted the ship’s engine, allowed the ship to flood, hindered evacuation and made finding survivors more difficult.

The board produced 80 findings about problems with weather forecasting, ship management and the inadequacy of open life boats in a storm. Investigators developed 53 recommendations, which the board planned to vote on Tuesday afternoon.

“I’m confident that this tragedy at sea will improve safety for future generations of mariners,” said Robert Sumwalt, the board chairman. “The El Faro didn’t have to sail into Hurricane Joaquin and, having met the hurricane, it didn’t have to sink.”

More on the El Faro sinking:

Captain's mistakes led to El Faro sinking, Coast Guard report says

'Help me. I'm a goner': Doomed El Faro ship's horrifying last moments

Why did El Faro sail into a storm?

Davidson refused crew suggestions to take a slower, safer route around the Category 3 storm with 150 mph winds, according to transcripts from the ship’s recorder. He received forecasts late through desktop weather service, and rejected a crew suggestion to alter course at 2 a.m.

As the storm worsened, the Faro tipped in the wind. Investigators said the tipping likely allowed an air gap in the pipe that drew oil to the engine from a pool in the bottom of the ship. The lack of oil forced the main engine to halt by 6 a.m., investigators said.

Around 7:12 a.m., the ship sent a distress message. At 7:27 a.m., the ship sent an emergency signal. At 7:29 a.m., the captain ordered crew to abandon ship. By 7:39 a.m., the recording ended.

The 510-page transcript of the ship’s recorder offered a chilling recitation of the crew’s final minutes. Davidson ordered crew members to wear immersion suits, toss rafts into the water and abandon ship.

"Ring the abandon ship," Davidson said. "Tell them we are going in."

A seaman repeatedly yelled, “Help me!”

"I'm a goner!" a seaman said.

"No, you're not," Davidson replied.

The investigation found that while the ship remained intact, it flooded in several ways. Water was reported in the cargo hold at 5:43 a.m.

The second deck, a level below the main deck, had gaps open to the sea, but was typically watertight to prevent flooding of the cargo decks below.

But a second-floor crew hatch was open, either because a crew member left it open or because it popped in the storm, investigators said. That allowed water from strong winds and high seas to pour into the main cargo hold. Investigators recommended placing alarms on hatch doors that would send visual and audio alarms to a crew member.

Cars in the hold were lashed jointly to the floor with a long chain, rather than lashed individually as the cargo manual suggested, investigators said.

Crew members reported vehicles floating as the hold flooded. Investigators suggested that a floating vehicle might have ruptured a pipe that allowed more seawater to flow into the ship.

As the ship tilted and the cargo hold flooded, more water entered the ship through ventilation shafts. The shafts were left open to disperse gas fumes from cars in the hold to prevent fires. But investigators said crew members didn't routinely close the vents while sailing, which resulted in a flooding hazard.

“Staff believes that vessels should not have operational requirements to maintain ventilation closures in an open position when the same closures are treated as secured when the vessel’s stability and load lines are assessed,” said Eric Stolzenberg, who investigated the vessel’s architecture.

The search for survivors was also fraught with problems. Investigators discovered confusion over the ship’s final location on the ocean surface, but said it didn’t affect the rescue operations.

The Coast Guard, Navy and Air Force had to wait two days for the hurricane to pass before beginning to search for survivors on Oct. 3, 2015. Then 15 aircraft searched 195,000 square miles for the vessel.

The ship’s position from an Inmarsat satellite and the Coast Guard’s software described the location in degrees and minutes in different ways, with periods and colons, investigators said. The different interpretations led the Coast Guard to think the ship was 23 nautical miles away from its last known location.

“The differences between location formats can create confusion,” said Jon Furukawa, who investigated survival factors. “Staff believes position errors did not affect the outcome of search and rescue efforts in this accident, but position information should be in a standardized format to eliminate the same error in future accidents.”

Board member Christopher Hart said he was surprised that the different location formats hadn’t been noticed as a problem in the past. But he was eager for the Coast Guard to develop a standard with the International Maritime Organization.

Open lifeboats, which were phased out on new U.S. ships in 1986 because they expose occupants to weather and have trouble navigating in a storm, remained grandfathered on the 40-year-old Faro.

The ship likely tipped too far for the crew to launch its open lifeboats during the storm, and it wasn't clear crew members were able to abandon ship, investigators found. But enclosed lifeboats, which protect occupants from the weather and have engines, could have been dropped off the side of a vessel without cranes, investigators said.

“We don’t know they would have survived, but enclosed lifeboats are the current standards,” Furukawa said.

Vessels should have life-saving equipment reviewed at least every five years and upgraded at least every 20 years, investigators recommended.

The ship’s emergency radio beacon didn’t provide GPS information, making it harder to track the beacon. El Faro’s beacon was detected at 7:36 a.m., but the location couldn’t be fixed before it stopped transmitting for an unknown reason.

The wreck was found 77 nautical miles from its last known location on the ocean surface, a space strewn with immersion suits and a damaged life boat.

Investigators recommended emergency beacons provide GPS data. Hand-held beacons with GPS could also help searchers find survivors, investigators recommended.