U.S. Coast Guard Releases El Faro Report


November 2017


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Two years after the tragic sinking of the SIU-crewed El Faro, the United States Coast Guard released its Report of Investigation into the loss of the vessel and all 33 people aboard.


The SIU hall in Jacksonville, Florida, on Sept. 30 hosted a meeting of Coast Guard officials and El Faro family members – a day ahead of the report’s official release. Agency representatives explained the findings of the two-year investigation, as well as the recommendations made by the report.


More than 200 people returned to the hall the next day, Oct. 1, for a memorial event on the two-year anniversary of the El Faro’s loss. Elsewhere in Jacksonville that day, the Coast Guard’s Marine Board of Investigation (MBI) issued its report to the public, along with safety recommendations for the industry based on the findings of the investigation. (The full report is linked in an Oct. 3 post in the News section of the SIU website. It is a 199-page, PDF document.)


Capt. Jason Neubauer, chairman of the MBI, stated, “The publication of our report is the culmination of an extensive effort to determine the cause and identify actions to prevent future casualties. Our thoughts today are about the 33 mariners lost during the casualty and their loved ones. The personal impact of this tragedy was the driving force in our work.”


The MBI collected and analyzed data from the wreck of the El Faro, working closely with the National Transportation Safety Board to ensure they had done an exhaustive discovery of every piece of information. After the salvage of the vessel’s voyage data recorder, the MBI was able to analyze the data and develop a list of recommendations for further actions to improve safety and accountability.


The MBI concluded that the primary cause of the casualty was the decision to navigate the El Faro too close to the path of Hurricane Joaquin. The MBI also uncovered evidence of an ineffective safety management system within the operating company, and failures by both the Coast Guard-delegated representative and the Coast Guard itself to provide effective oversight of the vessel’s compliance with safety regulations.


The report contains 31 safety recommendations to address issues determined to be contributing factors to the incident, including: n 17 recommendations to strengthen regulations;


- Three recommendations to improve competencies for delegated surveyors and Coast Guard marine inspectors;


-Three recommendations to improve the efficacy of stability reviews and major modification determinations;


- Four recommendations to improve Coast Guard oversight of functions delegated to third party certification organizations;


- Three recommendations to improve search and rescue capabilities; and


- One recommendation to improve the processing and delivery of weather forecasts.


After reviewing the report, along with additional comments that may be provided by the “Parties in Interest,” the Commandant of the Coast Guard will publish a decision outlining the final agency actions that will be taken in response to the recommendations. Rear Adm. John Nadeau, the assistant commandant for prevention policy, will lead the commandant’s efforts in response to the recommendations.


“I want to express my deepest condolences to the families of the mariners who were lost in this tragedy,” said Nadeau. “I would like to thank the Marine Board for their exhaustive efforts over the past two years. This has likely been the most transparent Board in Coast Guard history and the evidence uncovered during the investigation has spurred change within the Coast Guard and maritime industry. Going forward, we are committed to ensuring that the Coast Guard learns all we can from this casualty and takes action to improve our marine safety program. Further, I hope that all vessel owners and operators, classification societies, mariners, and other organizations and individuals who have responsibility for maritime safety will review the report and implement changes to improve maritime safety.”


The operator, Tote, issued a statement on the release of the findings, stating in part, “The El Faro and its crew were lost on our watch and for this we will be eternally sorry. Nothing we can do will bring back the remarkable crew, but everything we do can work to ensure that those who go to sea, serving us all, are in ever safer environments. The report, which we and so many others, whom we would like to thank, worked relentlessly on, is another piece of this sacred obligation that everyone who works upon the sea must study and embrace. The report details industry practices which need change. We are committed to working with every stakeholder on these comments and recommendations. We remain focused as we have from the start, on caring for the families of those we lost and working daily ashore and at sea to safeguard the lives of all mariners.”


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