Maritime accident investigation reports for collisions, explosions, capsizings and allisions and the lessons learned within those reports are detailed in the National Transportation Safety Board’s (NTSB) Safer Seas Digest 2017, which was released Nov. 8.
The publication is a compendium of 41 marine accident reports for accidents involving fishing, offshore supply, cargo, passenger, tanker, towing and government vessels. Tragically, some of these accidents also resulted in loss of life, injuries, and significant property damage.
The Safer Seas Digest provides links to the full investigative reports and related documents on the NTSB’s website. The digest contains information that can help mariners prevent future accidents, and help the maritime industry build and sustain a culture of safety at sea.
The lessons learned are highlighted in 11 categories including watertight integrity, heavy-weather operations, fatigue, bridge resource management, distraction, anchoring, preventive maintenance, safety management systems, monitoring rudder order response, vessel abandonment and VHF reception.
The failure to maintain watertight integrity was the No. 1 cause of vessel losses during the 2017 reporting year. To protect personnel, vessels, and the environment, NTSB recommends owners to conduct regular oversight and maintenance of hulls and watertight bulkheads, even during layup periods. This oversight should include monitoring the hull thickness, maintaining sufficient marine coatings, and using cathodic protection systems. Known issues with watertight integrity and wastage need to be repaired using permanent means. NTSB advises that bilge piping and pumps should be in good working order and alarms should tested regularly. Also, watertight doors should be checked and maintained to ensure they are properly sealed when closed and be closed at all times while underway.
One of the 41 marine accident reports related to the April 2017 collision between the tugboat Cerro Santiago and U.S. Coast Guard cutter Tampa, in the Panama Canal. Although the tugboat was not damaged, the cutter sustained $170,018 in damage to the stern as well as to various systems in the steering gear room. The NTSB determined that the probable cause of the collision was the failure of the master of the Cerro Santiago to maintain a vigilant watch due to fatigue.
The report also includes the completion of the investigation into the October 2015 sinking of the cargo vessel El Faro during tropical storm Joaquin, which was a watershed moment for marine safety. El Faro had sailed close to the eye of the storm and was lost at sea with all hands.
The NTSB investigation was critical of El Faro’s captain, as was the U.S. Coast Guard incident report, stating that he made decisions that put his crew and vessel at risk including inadequate course corrections, relying on outdated weather sources, declining to change course or return to the bridge, introducing a port heel to shift water on the weather deck from starboard to port, and a late call to muster the crew. The investigation noted that two members of the bridge team suggested or hinted that they disagreed with the captain’s decisions, but the captain disregarded their concerns.
In addition, NTSB found the company’s safety management system did not provide the officers and crew with the necessary procedures to ensure safe passage, watertight integrity, heavy-weather preparations, and emergency response during heavy-weather conditions. Investigators determined that the vessel had no damage control plan or booklet.
The report also cited the lack of suitable survival craft. El Faro carried only open (not modern, enclosed) lifeboats. In addition, by the time the crew was abandoning ship, the severe weather, combined with El Faro’s list, made it unlikely that the side-mounted lifeboats could be boarded or launched.
The El Faro report makes numerous recommendations to prevent a similar disaster, including the implementation of better tropical cyclone forecasting, storm advisories, and weather dissemination systems; use of engines and other critical machinery that work at greater angles of inclination; enclosed lifeboats that can be launched at still greater angles of inclination, so that they can be launched even if engines or other machinery fail; remote open/close indicators for watertight doors and hatches; class-approved damage-control plans/booklets onboard all vessels, regardless of build date; and personal locator beacons for crewmembers.
This is the fifth year the NTSB has published the Safer Seas Digest. Publicly available online, the report is also available in print for industry stakeholders.