In a sharply worded report concluding its investigation of the 2015 sinking of the cargo ship El Faro as it tried to run through a hurricane on its way to Puerto Rico, the U.S. Coast Guard recommended civil penalties against the ship's owner.
TOTE, the owner, "did not ensure the safety of marine operations and failed to provide shore side nautical operations supports to its vessels," the report, released Sunday, concluded.
But it was also harshly critical of the ship's captain and crew.
Michael Davidson, the captain, not only made an ill-considered decision to sail through rather than around the hurricane, but also "failed to carry out his responsibilities and duties as captain of the vessel" during the last eight hours before it sank, the report said.
The Coast Guard would have filed negligence charges against Davidson and tried to have his license revoked if he had survived, Capt. Jason Neubauer, who headed the investigation, said at a news conference in Jacksonville, Fla.
The crew's "complacency" and "lack of training" also contributed to the loss of the El Faro, the report said.
But Davidson "was ultimately responsible for the vessel, the crew and its safe navigation," Neubauer said.
The report is the culmination of a two-year investigation that included 30 days of public hearings at which 76 witnesses testified. The Coast Guard also listened to 26 hours of voice recordings of the captain and crew from the El Faro's voyage data recorder that was retrieved from the wrecked ship, 15,000 feet deep in the ocean.
TOTE released a statement Sunday saying the report "is another piece of this sacred obligation that everyone who works upon the sea must study and embrace. The report details industry practices which need change.
"The El Faro and its crew were lost on our watch and for this we will be eternally sorry."
The El Faro went down Oct. 1, 2015, off the coast of the Bahamas, taking Davidson and 32 crew members with it. The report called the sinking "one of the worst maritime disasters in U.S. history," and it was generous and wide-ranging in assessing the blame.
The report criticized such things as the El Faro's design, how its cargo was loaded, National Hurricane Service weather data and the Coast Guard's own inspection procedure.
But some of the toughest language was reserved for the captain. Davidson "misjudged the path of Hurricane Joaquin and overestimated the vessel's heavy weather survivability while also failing to take adequate precautions to monitor and prepare for heavy weather," Neubauer said. "He failed to understand the severity of the situation, even when the watch standards warned him the hurricane was intensifying."
The report said Davidson made a series of poor decisions on El Faro's final voyage, starting with not changing the ship's route between Jacksonville and San Juan rather than sail into a hurricane with 150 mph winds.
His final, fatal mistake, the report said, came at 5:54 a.m. when he changed course to put the wind on El Faro's right side, where it pushed the ship to list heavily to the left. That, Davidson believed, would have enabled the crew to reach and close an open hinged hatch on the right side that was allowing water into the ship.
But because the captain had already ordered some of the ship's ballast to the left, El Faro's list was too steep, and as cargo and water rushed to the left, El Faro tilted even farther. The result was that the engines died at 6 a.m.
That left the ship at the mercy of the storm, the report said, and Davidson gave the order to abandon ship about 90 minutes later. But in the El Faro's open-top lifeboats _ all that was required by the 1986 regulations under which the ship operated _ the crew had little chance of survival in the middle of the storm.
TOTE also got a scathing evaluation in the report.
Along with the captain, the company "did not adequately identify the rest of heavy weather when preparing, evaluating and approving the voyage plan" before the El Faro left Jacksonville, the report said. And TOTE "did not provide the tools and protocols for accurate weather observations," it added.
The company had not filled an opening for a safety officer aboard the El Faro, the report said, spreading out those duties among other managers at the same time it was violating regulations on crew rest periods and working hours.
The resulting weariness of the crew played a role in the sinking, the report said: "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."
In Jacksonville, relatives said they were satisfied with the report.
"It just seems on both sides, there was really negligence," said Joanna Johnson, whose son, Lonnie Samuels Jordan died aboard the El Faro. "It's just a shame that had to happen."
