12/21/2017: Coast Guard releases Final Action Memo regarding S.S. El Faro sinking and loss of 33 crewmembers

From the desk of Rear Adm. John Nadeau, assistant commandant for prevention policy

Today, the Commandant, Adm. Paul Zukunft, released the Coast Guard’s Final Action Memo regarding the 2015 S.S. El Faro sinking and the loss of its entire crew. In the Final Action Memo, Adm. Zukunft approves the findings of fact, analysis, and conclusions detailed in the Marine Board of Investigation’s Report of Investigation, essentially marking it as the official Coast Guard position on the cause of the marine casualty.

Following the Commandant’s review of the ROI and comments received from Parties in Interest and families of the crew, he concluded that the primary cause of the casualty was the decision to navigate El Faro too close to the path of Hurricane Joaquin. Contributing factors include: (1) an ineffective safety management system within the operating company, TOTE Services Incorporated; (2) American Bureau of Shipping’s failure to uncover or otherwise resolve longstanding deficiencies that adversely affected the safety and seaworthiness of vessels on multiple occasions; and (3) failure of the Coast Guard to adequately oversee the third party in this case. The investigation also reveals that the Coast Guard has not sustained the proficiency and policy framework to do so in general.

In the Final Action Memo, Adm. Zukunft directs final agency actions that the Coast Guard will take in response to the Board’s recommendations. As assistant commandant for prevention policy, I will lead this effort. These actions include:

• New flag state guidance to improve the development, implementation, and verification of Safety Management Systems;
• Changes/updates/improvements to Coast Guard management of the Alternate Compliance Program and accountability of Authorized Classification Societies;
• Advanced Coast Guard marine inspector training that includes alternate inspection programs, auditing principles and other contemporary topics;
• Guidance to mariner training institutions to provide training in advanced meteorology topics;
• Regulatory actions related to high water alarms and periodic vessel deadweight surveys;
• Engagement at IMO to provide flooding detection in cargo holds of new and existing multi-hold cargo ships;
• Discussions with NOAA regarding improvements to its maritime weather forecasting products;
• Working with the Coast Guard’s Response Directorate to institute Search and Rescue related equipment changes.

The Coast Guard takes the implementation of these safety improvements very seriously. In the coming weeks and months, my staff and I will work with industry, IMO, Congress, and all maritime stakeholders to reinforce all levels of the safety framework. First and foremost, every operator must commit to safety by embracing their responsibilities under the ISM Code. Secondly, Recognized Organizations must fully and effectively perform their duties and responsibilities. Finally, the Coast Guard, must, and will, provide the final safety net with effective and sustainable policy, oversight, and accountability.

I recently had the opportunity to visit the El Faro memorial in Jacksonville. It was a very moving and humble reminder that this tragedy is a call to action for the entire maritime community. I look forward to working with you to answer this call.

Editor’s note: The Final Action Memo and other documents related to the El Faro hearings and investigation are available in the Coast Guard’s digital FOIA reading room.

This blog is not a replacement or substitute for the formal posting of regulations and updates or existing processes for receiving formal feedback of the same. Links provided on this blog will direct the reader to official source documents, such as the Federal Register, Homeport and the Code of Federal Regulations. These documents remain the official source for regulatory information published by the Coast Guard.

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