The following article was posted October 1 on the U.S. Coast Guard's Maritime Commons Blog and is available online.
The Coast Guard announced during a news conference in Jacksonville, Florida, Oct. 1, 2017, that it has released its Report of Investigation into the loss of 33 mariners and the U.S. cargo ship, El Faro.
On the morning of Oct. 1, 2015, as Hurricane Joaquin roiled the Atlantic Ocean east of the Bahamas, the Coast Guard received a distress alert from the El Faro. During the following week, Coast Guard assets searched 165,500 square miles in an attempt to locate the vessel and rescue the 33 mariners (28 U.S. and five Polish nationals) on board.
As the Coast Guard suspended the search, the Coast Guard convened a Marine Board of Investigation (MBI) to collect and analyze evidence and develop recommendations for further actions to improve safety and accountability. During the evidence collection phase of the investigation, Coast Guard investigators worked very closely with investigators from the National Transportation Safety Board to conduct a comprehensive discovery of information, including an underwater survey of the vessel's wreckage and salvage of the voyage data recorder.
Capt. Jason Neubauer, the 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 concluded that the primary cause of the casualty was the decision to navigate El Faro too close to the path of Hurricane Joaquin. As the MBI expanded the investigation to explore other contributing factors, it 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:
- 17 recommendations to strengthen regulations;
- 3 recommendations to improve competencies for delegated surveyors and Coast Guard marine inspectors;
- 3 recommendations to improve the efficacy of stability reviews and major modification determinations;
- 4 recommendations to improve Coast Guard oversight of functions delegated to third party certification organizations;
- 3 recommendations to improve search and rescue capabilities; and
- 1 recommendation to improve the processing and delivery of weather forecasts.
The report, its recommendations, and supporting testimony and appendices are available online for download from the El Faro's public information news website.
After reviewing the report, its recommendations and 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."