(WVEC/ WTLV) -- A weary crew, an aging ship, and poor weather forecasting are among the reasons the Coast Guard Marine Board of Investigation cites for the sinking of the El Faro cargo vessel two years ago today.
The 790-foot freighter sank in October 2015 after losing propulsion while traveling between Jacksonville and San Juan, Puerto Rico.
The ship got caught in 155 mph winds and strong seas of Hurricane Joaquin. All 33 people on board died, including a crew member from Virginia Beach
Why? And what now? Final report on El Faro tragedy due Sunday
The 199-page Marine Board of Investigation Report of Investigation (ROI), released Sunday morning, comes after three, two-week public hearings and hundreds of hours of review. The report finds plenty of targets for blame in the tragedy. Among the findings:
- TOTE did not ensure the safety of marine operations and failed to provide shore side nautical operations supports to its vessels.
- The Master of EL FARO, Captain Michael Davidson, failed to carry out his responsibilities and duties as Captain by not changing course
- The National Hurricane Center created and distributed tropical weather forecasts for Hurricane Joaquin that proved to be inaccurate
- The cumulative effects of anxiety, fatigue, and vessel motion from heavy weather degraded the crew’s decision-making and physical performance of duties during the accident voyage.
- The ship’s increase in cargo carrying capacity in a 2005-2006 conversion made the ship less stable but was not reviewed as a “major conversion” by the Coast Guard.
- Once the ship’s hold began, flooding, the crew “did they have equipment or training to properly respond”
- The captain failed to notify shore support of his order to abandon ship, delaying Coast Guard rescue response
- The ship’s outdated open lifeboats were “completely inadequate to be considered as an option for the crew to abandon ship in the prevailing conditions.”
The report also finds violations of standards that could be subject to civil penalties. Among them:
- There were numerous violations of crew rest hours standards
- There was no safety orientation for the Polish riding crew, aboard to repair the ship’s boilers
- TOTE failed to notify the Coast Guard of repairs to lifesaving gear
- TOTE failed to notify the Coast Guard or regulators of repairs to EL FARO’s main propulsion boiler superheating piping on August 24, 2015.