This is an excellent letter from a retired Captain giving a very thorough insight into what we as Mariners face and deal with every day in this industry. Anyone who has been in a supervisory role out here knows intimately well exactly what Captain Loftus is talking about. It's a very real problem, and it's systemic.

Simply saying that it's the Captain's fault and dismissing all other possibilities is a mistake, and I truly hope that the findings of this investigation bear out the points expressed in this open letter.

It is very long but is worth the read if you have an interest as to how in the modern age an American ship can find itself sailing into a hurricane and sink with all lives lost.

El Faro – An Open Letter To Investigators
February 3, 2017 by Editorial

Editor’s Note – The following letter was written by Captain John Loftus, a Master Mariner and acclaimed whistleblower with 42 years experience aboard American flagged ships, to Captain Jason Neubauer, Chief of the U.S. Coast Gaurd’s Office of Investigations & Analysis. This letter was published unabridged with the permission of Captain Loftus and Captain Neubauer. –John Konrad

“Dear Captain Neubauer,

I write regarding the tragic loss of the Steam Ship El Faro, and your current investigation. My concern, and that of other mariners, is that something may be overlooked. I know your agency tends to be thorough; nonetheless I would like to offer some perspectives, and opinions, based on my extensive experience sailing in the U.S. Merchant Marine.

If your investigation is to be truly thorough, then looking at all possible avenues of approach would seem warranted. This was something I believe you mentioned in your opening remarks, i.e. that the purpose of the investigation was to find out what must be changed, so that future accidents could be avoided.

I am a graduate of the U.S. Merchant Marine Academy, class of 1971 Dual License, which means I graduated with both an Unlimited 3rd Mate’s License as well as an Unlimited 3rd Engineer’s License (Steam & Motor). I have held an Unlimited Master’s License since 1978. My career (and personal travel) that spanned 42 years took me to over 100 countries on a variety of different types of vessels, including tankers, break bulk, LASH, SEABEE, and containerships. My first command was with U.S. Lines in 1985 as Master of the American Resolute. At that time, I was one of the youngest Masters with that company since WWII.

I was engaged as a ship’s Master from 2001 through 2013 on the Jacksonville (JAX) to San Juan (SJU) trade route. This encompassed two container ships, the Horizon Discovery, and the Horizon Trader, where I was billeted as permanent Master.

I know the trade route well and often undocked JAX at the same time as the TOTE ships. Quite often we would sail parallel, in sight of each other, on the way to SJU. I retired in 2013.

In regards to this investigation, my position is somewhat unique. Not only did I sail the same trade route as El Faro for 13 years, I was also terminated for reporting regulatory non-compliance issues to both the ABS and USCG. Also, I am the first American Deep Sea Master to bring successful litigation, under the “Seaman’s Protective Act”. Thus in addition to normal seafaring experiences, I also have another side of the story to elucidate. One that is perhaps too often buried, one that companies do not want discussed, one, which can put Seaman, Ships, and the Environment at risk!

One of the first statements I remember hearing, which was released by the owner’s (TOTE), when the El Faro went missing, was that they had an experienced and capable Master onboard. Who else would they billet as Master, someone incapable? My very first reaction, and my interpretation, to that statement, was they (TOTE) were setting up the Master as scapegoat for what may be underlying problems, possibly not so noticeable, particularly for those outside the industry.

SCHEDULE PRESSURES

On the JAX/SJU trade route, time is of the essence. There is little make up time, at sea, built into the schedule. Additionally, there are other reasons to get the ship off dock, i.e. dockage fees in some cases, and most notably, being able to steam slower and hence burn less fuel. Vessels are kept at the dock for a minimum amount of time, which reduces time for repairs. Older ships like the El Faro, or the ships I served aboard, are always in need of repairs; it is the nature of the beast. This doesn’t necessarily make them unsafe in a perfect world, but on quick turnaround trade route with repairs constantly delayed, safety quite often takes second place, to schedule. Mariners have little to say when repairs get done. We report the need for repairs. Port Engineers, Engineering Departments, Schedules, and Budgets decide when the repairs are scheduled.

THE INTERNATIONAL SAFETY MANAGEMENT CODE (ISM)

Numerous regulations are in place to keep ships and the crews safe. The problem lies in the oversight of the regulations.

Prima facie, the ISM Code which requires a Safety Management System, would seem to make everything open, transparent, and above board. Indeed if properly implemented it would. Companies like having a proper paper trail, as required by ISM Code to show how they are observant with their Safety Management System. Part of the Safety Management System is a requirement for reporting abnormalities, usually done through a process of “Corrective Action Reports” (CAR’s). CAR files are required to be maintained onboard, and ashore, and are available for either the ABS (American Bureau of Shipping) as classification society, or the USCG (United States Coast Guard), to view while onboard.

Unfortunately, this system is deeply flawed. Company’s do not like having CAR’s written for anything that pertains to a regulatory non-compliance issue, or other major safety issues. They don’t like the attention a CAR brings to this type of situation and they don’t like the paper trail. They would prefer that CAR’s reference minor personal injuries, and how they have corrected and took positive action to prevent a similar accident. This is the paper trail they would like to show; positive action, which makes the company look good. Of itself, this is all well and good and a positive step for better safety onboard the ship, but it often does not address the more major issues. In the end, no company wants to lose time at the dock doing repairs they can put off to a more convenient time. If the berth window is short, so much the worse!

Consequently, there is an undercurrent from management about writing CAR’s that pertain to major safety violations, or regulatory non-compliance issues. Retaliation hangs over the head of personnel, who document what companies do not want documented. So, whom do seamen have to turn to for protection? Only their particular labor union, if they belong to one, and in some cases there are limits to the protection unions can provide. I have seen it over, and over, where command officers are reluctant to write CAR’s on Major Safety Issues or Regulatory Non-Conformities. So, the very Code (ISM) that was developed to make seafaring safer, has a major systemic failure!

As in most of Corporate America, there is a drive for profits at almost any cost. Just read the reports on the Deepwater Horizon, another accident that should not have happened!

THE ALTERNATE COMPLIANCE PROGRAM (ACP)

The Alternate Compliance Program came into being in 1990’s, and was later updated after the loss of the Alaskan Ranger and five deaths. While there was evidence of failure of the ACP at the time of loss of the Alaskan Ranger, it was decided to revamp the program and make it better. In my opinion, the program remains a failure. Later in this letter, I will give specific examples.

My experience for the last 15 years has been, that the primary regulatory agency for the safety of U.S. Flag Merchant Ships, via the “Alternate Compliance Program” (ACP) the American Bureau of Shipping (ABS) does not fully do their job.

Not only that, but I have brought specific examples up to more diligent ABS Inspectors, or ABS management, and they just shrugged, or did not want to hear about it. They never want to answer, or investigate, about another ABS Inspector not getting the job done properly.

The USCG is relying on an agency that is being paid Work Order by Work Order to do surveys, and who too often looks the other way. I have seen this repeatedly, and so have many of my colleagues within the industry. Marine Inspection quality has steadily declined over the last 15 years. As the USCG retreated from active Marine Inspection, younger USCG Inspectors became less well trained. Today, we have fewer and fewer USCG Marine Inspectors who can train the younger enlistees.

As a Master, I was vocal about bringing up major safety issues and regulatory compliance violations. To facilitate repairs and to draw attention to problems, I wrote Corrective Action Reports (CAR’s) where required.

In the end, I became a target, and was subjected to retaliation by the company where I had worked, with an unblemished record, for twenty years. Fear of retaliation, whether direct, or implied, is a primary reason other mariners take chances they should not have to take, or work under unsafe conditions and outside of regulatory compliance. Again, I have seen it over and over where ship’s officers are reluctant to write CAR’s, demand repairs, or report unsafe working conditions to authorities. Maritime companies do not want to lose time (schedule), or money, and therefore push their personnel to make do, often at the price of safety, or regulatory compliance. Isn’t this just the type of crafty operating philosophy that led to the Deepwater Horizon debacle? Companies appear to look good on paper, but the reality is sometimes quite different. Violations of the International Safety Management Code (ISM) are problematic.

Retaliation is a methodology, to not only remove conscientious people, but also to cast a huge and pervasive shadow of intimidation. This allows managers to get what they want, regardless of legal requirements. In 2014, I brought forward the first successful litigation under the “Seaman’s Protective Act” for a Deep Sea Master. Since my lawsuit, which I won in May of 2015, two other Ships’ Masters have contacted me about being removed from their jobs due to retaliation. These are men, like myself, who were trying to keep their ships, and crews, safe as per the requirements of U.S. Law. In my situation, it cost over Two Hundred Thousand Dollars, and two years, to get my litigation to trial. Most people are not going to make a similar expenditure, in hope of winning their litigation; nor should they have too, especially if they have already lost their job. The initial advantage favors the company, who is not operating properly under the law. How do we change that advantage and level the playing field?

The Alternate Compliance Program (ACP) is a failure. It has been for years. This is the program where the ABS stands in for the USCG to do annual and five-year inspections and certification. They are not thorough, and the USCG, with reduced manpower, has been reduced to do a quick walk around the vessel, and accepting the ABS Inspector’s report. It is not a good system. You can go back and read the reports on the sinking of the Alaskan Ranger in 2008, a vessel enrolled under the Alternate Compliance and Safety Agreement.

When I took command of my last ship, the Horizon Trader, in April 2007, there were 168 hatch cover dogs missing, or inoperable, (about 75% of required were missing). Yet this was overlooked by the ABS during annual inspections; please notice the plural on the word inspection! When I made demands for the company to notify regulatory agencies, they did not, although they were required to do so by law. Their obfuscation of the law was complete, open, and documented. Shortly afterward, during shipyard in China (June 2007), I was harassed, assaulted, and battered by the very Port Engineer who had continually refused to have the repairs made. He was later promoted to Senior Port Engineer! Following a “5 year special survey”, the ship sailed from the Chinese Shipyard with no repairs effected to hatch cover dogs and through two Hurricane Zones (by another Master). Lack of watertight integrity is, no doubt, part of the reason for the El Faro sinking. Indeed, I was in a storm in March of 2013, battling 100 knot winds, huge swells, and seas, and rolls to 50 degrees, about 200 miles East of Chesapeake Bay; there is absolutely not one doubt in my mind that my ship, the Horizon Trader, would have sunk without those repaired hatch cover dogs.

It would be impossible for the non-mariner to understand phenomena such as sailing into a Hurricane. For reference, I quote a passage from The American Practical Navigator – “As the center of the storm comes closer, the ever stronger winds shriek through the rigging, and about the superstructure of the vessel. As the center approaches, rain falls in torrents. The wind fury increases. The seas become mountainous. The tops of huge waves are blown off to mingle with rain and fill the air with water. Visibility is near zero in blinding rain and spray. Even the largest and most seaworthy vessels become virtually unmanageable, and may sustain heavy damage. Less sturdy vessels may not survive. Navigation stops as safety of the vessel becomes the only consideration. The awesome fury of this condition can only be experienced. Words are inadequate to describe it.”

The last major U.S. Flag vessel sinking was the Marine Electric, after departing the entrance to Chesapeake Bay, and that also had watertight integrity issues. How do regulatory agencies allow that to happen? The regulations are in place; the oversight is NOT!

{Editor’s Note: Prohibiting programs like the ACP was the NUMBER 1 recommendation in the Marine Electric Investigation Report (page 122) -JK}

STCW – Standards for Certification and Watch Keeping

There are other problems as well. Three Mate ships are continually in violation of the STCW requirements for rest. Fatigue is a recipe for poor decision-making and this is also rampant within the Maritime Industry. This is particularly true on a fast turn around trade route like the JAX/SJU. More then once I have seen and heard of falsified documents relating to rest periods. Around, 2005, I was Master on the Horizon Discovery when it was reduced from a 4 Mate to a 3 Mate ship on the same run as El Faro (JAX/SJU). When I notified the company, in writing, I would hold the ship at the dock, rather then violate STCW, I was given back the 4th Mate. I was not held in high esteem within the executive management system!

The USCG sets the manning scales for commercial vessels, but they do not properly investigate how those manning scales are actually deployed. I have seen no oversight about rest periods, or the violation of STCW rest periods. The USCG seems to have taken a deaf ear on this important issue, although it has been broached many times. Captain Neubauer, where is USCG’s regulatory oversight? Additionally, fatigue, both short, and long term, are not factored into the equation although many studies have been done to address this very issue. Notice, most tankers have gone back to 4 Mates due to the high liability costs if there is an environmental mishap (oil spill). On other types of vessels the manning scale has been squeezed back and personnel are overworked, and mentally fatigued. Just what was the long term effect on the El Faro of standard 12 hour days for the Mates and Engineers? Were decisions made wisely?

The USCG does not monitor how extra equipment put onboard ships places demands on the ship’s crew outside of the regular working duties. As an example, I will offer the carriage of “refrigerated containers”, of which I carried many thousands over the years. There is the need for power to run the refrigeration equipment in each unit, typically a 40 or 45 foot ISO container. On my ships, both the Horizon Discovery, and Horizon Trader, this required additional portable generators to be carried; also extra work for the Electrician, and quite often the Chief Engineer, and sometime another Engineers. We also had an additional semi-permanent generator placed on the main deck.

On both of my ships, it was of poor design and required a disproportionate amount of repair and maintenance by the ship’s crew. It was not uncommon for the Chief Engineer, 1st Engineer, Electrician, and other Engine Room personnel to be tied up for 8 hours or more. Meanwhile, routine operating maintenance was not being done. It was part of the slippery slope that led to crisis management. Yet manning scales were never adjusted so that proper maintenance of the ship could be kept up. Not to mention the fact that 40 year old ships need more maintenance then a new ship. As the workload increased, the manning scales remained the same, or decreased.

On the El Faro, just what was the impact of the 12-hour days the 3 mates worked? It becomes a long grind, and mental perspicacity declines inversely as the time onboard increases. Was the scuttle left open, not properly shut, not in good repair, or forgotten to be checked? Was someone not at the top of his or her game?

Ship’s Masters, and crews, are reluctant to say anything about STCW or Rest Periods for fear of their job. Something is wrong with this picture. While you assimilate that statement, think of the lives that have been needlessly lost on the El Faro, and the need for change!

Captain Neubuaer, as part of your investigation I offer the following suggestions:

1. For starters, I bring to your attention, the incongruity of the ABS, as a named party to the Marine Board of Investigation, supplying technical expertise. The ABS is a major part of the problem!

2. Consider deputizing Professional Mariners, to help digest the mountain of data your Board is assimilating. People who have been in command positions on merchant vessels have a different perspective on the how and why, then do the USCG. The Coast Guard is generally looking at things from a regulatory point of view. Mariners look at things from an operational point of view. The two are not always the same.

Here, I will give just two examples from the testimony I watched:

A. There was a lot of discussion, and questioning, about the El Faro anemometer not working, and the importance given to that piece of equipment. There was a debate between the Board and a Witness about the importance, and relevance, of the anemometer. Anemometers are indeed important pieces of equipment. Nonetheless, the anemometer was not going to save the El Faro. Indeed, it was not going to change the route chosen, or the need to change route. My inference from the Board questioning was that without the anemometer, and darkness, there was no information about the wind. i.e. the inability to see the wave condition and Sea State. Mariners can feel the wind, and certainly feel the motion of the ship in increasing seas and swells. From a Mariner’s perspective, even in the dark, a good mate can go out on the bridge wing and estimate the Relative Wind and work a reverse solution to get the True Wind. The more important questions about the anemometer is why it wasn’t repaired. Why were repairs delayed? Was there a CAR written?

B. There was questioning from the Board Naval Architect, who asked several times about the number of slack tanks, inferring the increase in free surface moment and the affect on GM. From what I remember there was no good answer given, nor did he seem to understand the practical operational implications. Yet on Merchant ships, there are usually more then one set of slack tanks. Yes, this is not what is recommended by the Ship’s Stability Books, at least the ones I have read. Pocketing occurs at approximately 98% full on most tanks, (the point where free surface is usually no longer considered) yet often times tanks are often carried at less then 98% full, especially fuel oil tanks. There is a reason for this, and it has to due with tanks burping causing a fuel oil spill on deck, and a possible MARPOL violation. Masters and Mates account for this free surface correction when doing the stability calculations. Additionally, and rightfully so, ship’s engineers don’t want to load to 98% full as it could lead to problems if communications, valve mis-function, or human error come into play. Some ships have fuel overflow piping; I am not sure about the El Faro.

3. Look over carefully my Addendum 1, to see problems I have encountered, over the years with my own ships, and the ABS. Look for possible crossovers to the El Faro, namely lack of proper Marine Inspection. Just because the ABS issued the certificates, it doesn’t necessarily make the ship watertight or up to regulatory compliance. Certificates are just that, what really matters is the thoroughness of the Inspector.

4. Review of all CAR files, not only on the El Faro, but sister ships as well. See if there is a lack of CAR’s written on non-conformities, or repairs not getting done in a timely manner. If they mostly have to do with personal injury, and not repairs, then most likely there is a reticence by employees to write a paper trail. Fear of job loss, or other subtle retaliation, is the most likely cause. Generally, there is also a reticence by Chief Mates, and First Engineers to write CAR’s as they are hoping for future promotion. Additionally, for Chief Mates and First Engineers, there can be fear of the Master or Chief Engineer who does not want the paper trail making “their” ship look under par.

5. Review of relief notes among Masters, Chief Mates, 2nd Mates, Chief Engineers, First Engineers, and 2nd Engineers. Sometimes there are two sets of relief notes, the one that gets sent to the vessel superintendent, and another set between rotating personnel, which is more explicit. In the case of the El Faro, the personnel on vacation may well have all sorts of history files. The other avenue is to look at all the records on the sister ships, which may show how the ship was maintained.

6. Maintenance programs that upload from the ship to shore such as MAXIMO, or other software programs, that show maintenance performed, due, and overdue. Beyond this there may also be spread sheets on board that may, or may not, be shared with the company office. Review emails to vessel supers, and port engineers. And don’t overlook personal email files that may have been sent home, or brought home on flash drives, or personal computers.

7. Look at work for the next shipyard. Does it include work that should be done now and not later, or items that put the ship out of regulatory compliance while awaiting the next shipyard or dry-docking?

8. Interviews with Mates and Engineers who have rotated on either El Faro, or the sister ships in the past. This should be coupled with the permanently assigned employees on the El Faro, and sister ships.

9. Review of STCW files, and interviews with those working, or previously working, onboard TOTE ships. This should be coupled with a review of the overtime sheets, which give a better idea of actual hours worked. In many cases personnel are not even aware they are required to be given an “UNBROKEN” 6 hour rest period per day. Likewise under the CFR, those taking charge of their first watch after leaving port are to have had rest periods of 6 hours in the previous 12; this is often violated particularly on 3 Mate ships. STCW rest periods take a back seat to operations. The same with CFR requirements.

10. Look at schedule pressures put onto the Command Officers. Think of a containership in port for 12 hours or so. In JAX the Master may be up from 0300 (earlier in other ports such as NY/NJ or Philadelphia), get to the dock for a 0700 or 0800 cargo start, have meetings with vessel superintendents, boarding officials, and others, then sail around 1900. Chief Engineers, and First Engineers often have a similar schedule, with the Chief taking bunkers, and the First working with repair gangs, then maneuvering outbound. There is little chance for rest, and lots of pressure to get off the dock, and make schedule.

11. Why did Captain Davidson proceed towards Hurricane Joaquim? By all accounts that I have read he was a seasoned Mariner, and well thought of by people who knew him. Yet his decision to proceed is questionable. Particularly on a Con-Ro ship where water can easily ingress the weather deck area, in heavy weather, causing a virtual rise in KG, plus a free surface moment, both reducing the GM, i.e. the vessel’s stability. Not to mention the possibility of down flooding from boarding seas if there is leakage, or an open scuttle. What causes a Captain to make questionable decisions? It could be lack of knowledge, lack of forethought, arrogance, the will not to believe (i.e. it can’t happen to me), or pressure to maintain schedule. Throughout my career, I have seen Masters fall into all of the above categories. Even excellent, experienced Masters, can make poor decisions, and that I have seen also.

12. The El Faro, sailing JAX was not the problem. It was the continuance of the passage towards SJU. In fact it is not unusual for ports to order ships to sea when there is a hurricane approaching to preclude ships from being blown around a harbor, causing physical or environmental damage. In the case of the El Faro, the ship could have laid off of JAX and waited. Alternate routes could have been used. Even after proceeding towards SJU, there was ample time to re-evaluate. Proper evaluation could have caused re-routing back through North West Providence Channel, heaving to for further evaluation, and lastly turning around and going away from the track or predicted track.

13. There is no prudence heading into a hurricane, or trying to cross ahead of a hurricane’s track.

14. There were ample chances to re-evaluate the weather after sailing JAX. There are constant Marine warnings being broadcast and coming into the bridge, via GMDSS, and NAVTEX. There was a Weather Routing company (All Weather Systems) that TOTE employed. Although they did not subscribe to voyage routing, was Captain Davison aware he could have picked up the phone and called for advice? Finally, there was the Weather Channel.

15. Were the Master and Chief Officer trained in the use of the ABS Damage Control Manual?

16. What was the condition of the bilge alarms? How could a ship possibly get to a 15 degree list? Even a few degrees is noticeable and should have led to some investigation as to cause. It’s hard to believe that the only source of water ingress was one deck scuttle. Bilge alarms would have been going off and there should have been investigation as to the cause, long before there was any severe list, even accounting for wind heel.

17. What was the condition of the bilge alarms, how often were they tested, were any on repair lists?

18. Why did Captain Davidson wait so long to notify the company of the problems? Why did he not give a better description of the exact problems? What did he mean by “Navigational Incident”? An open scuttle is not a navigational problem.

19. One of the more outlandish things I heard during the testimony was the fact that the TOTE Port Engineer evaluated the Master as part of their SMS. Who approved this absurdity? All Maritime Academy’s have two paths towards licensing: Deck or Engine. The courses of study are different. A Port Engineer will never fully understand the complexity of the Master’s job.

20. The Port Engineer’s job is very complex also. They often are given less time then they need to get repairs done, and often without proper budgets to facilitate getting all the repairs scheduled.

21. One of the best witnesses I heard during the hearing so far was Captain Jack Hearn. And it was interesting to hear him intimate, that he had been let go for bringing up major safety problems on this class of ships.

22. Captain Hearn, and others, who have had extended experience on this class of vessel, should be asked further about water tight integrity problems over the years between cargo holds, water tight doors failure to seal properly, bilge systems, bilge alarms.

23. Has there been any “history” of water in the cargo holds, due to down flooding from seas boarding the weather deck?

Captain Neubauer, as I write this letter, the NTSB is evaluating the El Faro’s Voice Data Recorder (VDR). Let’s hope the information obtained from the VDR helps your team better understand what happened, and what steps to take going forward, to preclude another such catastrophe.

Should you or your staff have any questions, please feel free to contact me.



Attachments: Addendum’s 1 & 2

Addendum 1

Attach to letter for: Captain Jason Neubauer

Dated 29 NOV 2016

USCG, Marine Board of Investigation for El Faro

Some of my major interactions with the ABS spanning a number of years:

1. As Master of the Horizon Discovery during the period of approximately 2002 to 2007 I brought to the attention of the ABS, problems with portable power packs. These would be ISO – 40 foot containers which normally had two diesel engines, and two generators mounted inside the container. Problems were: Fire dampers not properly working, emergency shut offs not functional, fire suppression systems inoperable, CO2 cylinders not fully charged, CO2 bottles not properly inspected, ISO container inspections not performed, ISO containers not properly placarded. Generally, I was told by the ABS they were not responsible for these inspections or monitoring the condition of such containers. I believe, as the ACP surveyor, looking at the overall safety of the vessel they still had an obligation ensure the safety of the vessel.

2. In April of 2007, I took command of the Horizon Trader, and notified Horizon Lines about the condition of the hatch cover dogs. There was a mandatory requirement for Horizon Lines to notify the ABS, which I pointed out to management. They did not! If they had, there was also a mandatory requirement for the ABS to notify the USCG. The missing, or inoperative hatch cover dogs amounted to 168 dogs, or about 75% of the total required amount. How could the ABS consistently miss this amount of missing hatch cover dogs during their yearly, 2.5 year, and 5 year inspections? For that matter how could the USCG during their annual Certificate of Inspection review. This was so obvious that even a journeyman inspector should have picked it up.

3. Leaving the (Chinese) shipyard in the summer of 2007, following the 5-year special survey, none of the hatch-cover dogs were repaired. The ship proceeded Trans-Pacific to San Juan, PR and through two hurricane zones.

4. Leaving the (Chinese) shipyard in the summer of 2012, again following a 5-year special survey there were a plethora of issues. A Double Bottom manhole cover unable to be closed due to the wrong size stud ring having been welded in place. Cargo Hold tank tops filthy with debris, including crumbled foam insulation that clogged bilge well strainers. Bilge valves that did not operate. Fuel oil valves that did not operate. Ballast valves that did not operate. This was an automated ship where the valves were required to be operated from the engine room, yet many did not function. Additionally, many of the valves had been changed to hand operated butterfly valves in the cargo hold, with no reach rods to the upper cat walk. Fuel oil in the ballast system. Fuel oil in the bilge system. Electrical wires that had been cut during the shipyard were left live and dangling around the tunnels and cargo holds, about 40 were found. One Chief Mate almost got electrocuted; I was standing next to him. The Engine room bilge was full of debris, and had an unknown leak of continuous fuel oil into the bilge. Ballast vents in cargo holds, were cut near the tank tops, further eroding the watertight integrity of the ship. Catwalks were missing in places around the engine room, debris was everywhere, not only in the engine room, but the tunnels, and storage rooms. Nothing was ship shape! This is how the ship proceeded to San Juan from China.

After I joined the vessel in San Juan, Puerto Rico, approximately 85, forty two gallon trash bags of debris were removed from the engine room bilge. Another 300 bags of trash were removed from the cargo holds.

The new steering stand, which was onboard for installation in the yard, had not been installed, although there had been multiple failures of the original 45 year old steering stand.

Nine months after the shipyard, the valves still had not all been fixed, and the new steering stand not installed.

5. In April of 2013, I asked the ABS, under the ACP, for a formal review of the (Horizon Lines) Vessel Superintendent interfering with my “Master’s Authority” under the ISM Code. I did not get a reply, yet the company Designated Person, who was also notified by me, told me I probably wouldn’t get a reply. How would he know that? Months later, I made a second request to the ABS, and again silence; not even an acknowledgement of my two emails! Something is amiss here.

6. In 2014, I made a query to the ABS in Houston about the Horizon Trader’s flume tanks, and dump tanks, not being up to design parameters. The dump tanks had been partitioned off and there was not enough volume in the remaining dump tanks to handle the volume of water from the flume tanks. No answer was given.

Addendum 2

Attach to letter for: Captain Jason Neubauer

Dated 29 NOV 2016

USCG, Marine Board of Investigation for El Faro

My suggestions for legislative, or regulatory, changes are:

1. Writing a Corrective Action Report (CAR) should become a “legal requirement” of any licensed officer who notes a major safety deficiency, or any regulatory non-compliance. If it is mandatory for officers to report deficiencies, this takes away the anxiety of having the company bearing down on an officer who writes the CAR. Nobody knows the ship problems better then the seamen who work on the ship day in and day out. They are the best source to keep the ship safe! What needs to be removed is the level of intimidation, so that problems can be posted to the USCG, and repairs effected in a timely manner.

2. CAR’s reporting a major safety deficiency, or a regulatory non-compliance, should be required to be forwarded to the USCG.

3. ABS Inspectors, or USCG personnel, should be “required” to review the CAR file “every” time they board a vessel. My experience is that they, both the ABS and USCG, for the most part, don’t even look during annual inspections!

4. Consider ending, or modifying, the Alternate Compliance Program. This is a pay for play program, where there is a direct conflict of interest for the regulatory agency (ABS).

5. Double the punitive damage award maximum, under the Seaman’s Protective Act. This will help ensure management is reticent to think about using the tools of retaliation, or intimidation.

6. Make it easier for Seamen to qualify under the Seaman’s Protective Act.

7. Ensure that there are management personnel with extensive seagoing experience as part of the company’s operational team. Preferably two or three, who can review policy, and be available for consultation with the ship’s command officers. The Maritime Industry needs to get away from spread sheet managers, who have little or no seagoing experience, and may not even hold a Marine License.

Sincerely,

Captain John Loftus“

Link

Outstanding overview.

Thanks for posting this.

"It would be impossible for the non-mariner to understand phenomena such as sailing into a Hurricane. For reference, I quote a passage from The American Practical Navigator – “As the center of the storm comes closer, the ever stronger winds shriek through the rigging, and about the superstructure of the vessel. As the center approaches, rain falls in torrents. The wind fury increases. The seas become mountainous. The tops of huge waves are blown off to mingle with rain and fill the air with water. Visibility is near zero in blinding rain and spray. Even the largest and most seaworthy vessels become virtually unmanageable, and may sustain heavy damage. Less sturdy vessels may not survive. Navigation stops as safety of the vessel becomes the only consideration. The awesome fury of this condition can only be experienced. Words are inadequate to describe it.”"

This description makes the hair on the back of my neck stand up. Having spent 2 years on a Coast Guard Cutter before I went to flight school and then flying CG Falcons into many storms just prior to, during and after hurricanes, I recognize and appreciate the gravity of the weather conditions involved.

Its also hard sometimes to adequately describe the insidious nature of the continuous push by management to maintain schedules at nearly all costs. Pilot pushing at the airlines, mariner pushing by that industry.

The CG suffers from it as well. Our culture back in the day was "you have to go, but you don't have to come back". I flew into weather like that more than I care to remember, usually looking for another airman or mariner who probably shouldn't have been out in those conditions, but for various reasons were. Sometimes they made it, sometimes not. Was I lucky to survive or did I make better decisions? I am sure that plenty of it was luck. This Captain and crew ran out of luck that night for sure.

Another sentiment was "why do we check the weather, we are going any way". This concept will be familiar to any airline pilot or merchant mariner I would bet. Management provides us with numerous charts and exception tables to weather criteria to allow us to operate in conditions that are less than ideal, and often bordering on unsafe, so we push right to the edge. Occasionally we go past the edge and there is an incident or tragic accident. Ultimately the Captain and crew who made the decision to continue is to blame, but the company and the bureaucracies all need to be held to account as well.

So yeah this Captain made a bad decision, more than likely several, that led to the ultimate demise of the crew. The key is to find out which of the thousands of decisions he made could have been made differently and might have prevented the accident. There were undoubtedly dozens of other decisions, circumstances and actions by people other than the Captain that that made up the chain of events that led up to the sinking. Finding those is how we hopefully prevent the next accident from occurring.

quote:

Originally posted by Sigfan Roy:


So yeah this Captain made a bad decision, more than likely several, that led to the ultimate demise of the crew. The key is to find out which of the thousands of decisions he made could have been made differently and might have prevented the accident. There were undoubtedly dozens of other decisions, circumstances and actions by people other than the Captain that that made up the chain of events that led up to the sinking. Finding those is how we hopefully prevent the next accident from occurring.

This is what it boils down to. Para was right, in this instance the Captain never should have sailed directly into a hurricane.

I'm a Yacht Captain based about 200 miles from where it happened. The Captain of the El Faro could have followed the Florida coastline which was way out of the hurricanes projected path, and yeah it would've added about 150 nautical miles to the voyage and about 7.5 hours, but he would've gotten to Puerto Rico at the same time even if he made it on his initial voyage because he wouldn't have had to slow down. It was 3-5' seas the entire time off of the Florida coast. Even if ALL of the other situations happened, the ship would not have sunk and commercial tugs are located about every 50 nautical miles or less and could have towed her. So the decision to sail directly into the Hurricane is precisely what started the chain of events that led to her sinking and loss of all crew.

Just like the HMS bounty and many others that have been needlessly lost.

The number 1 cause of sinking in commercial shipping, is schedules.

quote:

Originally posted by jimmy123x:
So the decision to sail directly into the Hurricane is precisely what started the chain of events that led to her sinking and loss of all crew.

The chain of events started years before this ship ever left Jacksonville that day.

Did you read the letter?

The conditions that ship faced that fateful day are the same type of sea conditions she would've faced on the Alaska run on a routine basis. If she didn't go through that hurricane off of the Bahamas, she most likely would've experienced a marine casualty at a later date, only this time in the Pacific.

The whole point of Captain Loftus writing that letter was to hopefully press upon those doing the investigation--and who are not necessarily familiar with the environment that those of us who do work in this industry experience day to day--to not overlook the very real underlying factors.

I've personally dealt with every issue put forth by Captain Loftus. I've had to complete and correct CARs; I've dealt with ABS and their Alternate Compliance Program as well as annual inspections by fresh out of the academy Coast Guard inspectors whose only knowledge of Merchant Marine vessels came from watching Captain Phillips; I've constantly had to deal with office personnel who call themselves Captain even if their entire seagoing experience is a single month on a ferry boat. I've dealt with it all, the same as any other Captain, Chief Engineer, Chief Mate, and First Engineer who have worked for years in this industry. There's a problem here, and it's not going to be corrected by laying blame on one man and calling it case closed.

You may want to boil it all down until you have just the Captain at the bottom of the pot, but the very real fact of the matter is, take the Captain out of the broth, and the soup still tastes like crap.

Bumping this -

I did a quick search and did not see anything but Para recognized the story and provided the link in my now-locked thread.

A pretty incredible read if you missed it the first time around. I had to read the transcript of the below conversation a couple times. Cripes.

"We had a hull breach; a scuttle blew open during a storm," Davidson explained tersely. "We have water down in three hold, with a heavy list. We've lost the main propulsion unit, the engineers cannot get it going." He asked for her to patch him through to a TOTE official immediately.

"Can you please give me your satellite phone number and spell the name of the vessel?" she asked slowly. "Spell your name, please?"

Just an update on the final findings by the NTSB

https://media.defense.gov/2017...820187/-1/-1/0/FINAL PDF ROI 24 SEP 17.PDF

The Board holds the Captain primarily responsible and says they would have issued criminal charges had he survived. They said he misread the storm and overestimated his ship's ability and failed to monitor and prepare for heavy weather.

They recommend civil, but not criminal, penalties against TOTE including charges over not replacing a safety officer and crew rest periods and working hours.

They've also proposed 31 safety regulations and 4 administrative.

Right, like we did not already know this. So let the law suits fly now.

Right, wrong or indifferent. It was going to laid at his feet. It always is nowadays. Got to be someones fault. Got to blame somebody.

Don't get me wrong. I understand a bunch of people died.

But we all could die tonite, because of something someone one else did or didn't do.

Blaming someone is not going to change anything.

Including anything happening or not happening in the future. Just does not work that way. At least imho.

Primarily it is just about the money.