Part 1 - Merchant Vessels - Marine Accident Investigation Branch

CASE 11
Watch ‘Sleeping’ Leads to Grounding
Narrative
Just after midnight on a cold winter night, a
fish transport vessel with a cargo of live fish
sailed from a fish farm towards her discharge
port, approximately 6 hours away. The vessel
had been engaged in this trade for 7 years, but
recently her trading pattern had intensified
and she was completing one round trip every
24 hours.
There was very little wind, the sea was calm
and it was pitch dark outside. The mate was
alone on the bridge, navigating with the aid of
an electronic chart system while seated on the
wheelhouse chair. All the room heaters were
on, and the bridge was dark except for the
light from a few navigation instruments and the
CCTV for monitoring the live cargo.
A few hours into the passage, the vessel
approached a restricted transit area and the
The Lessons
1. The vessel’s intense trading pattern, the
significant amounts of defective equipment
on board, and the lack of continuity caused
by the high turnover of senior staff resulted
in the crew members working long hours.
With only four crew on board, all of whom
were busy, there was insufficient manpower
to ensure a dedicated lookout was maintained
during the hours of darkness. Ship owners
should periodically review their vessels’
manning levels and operating routines to
ensure that sufficient crew are on board
and, specifically, that a dedicated lookout can
be maintained during the hours of darkness.
2. The mate fell asleep because he was fatigued.
Not only was he getting insufficient sleep
- like the other crewmen - because of the
vessel’s operating cycle, defects and lack of
mate set a south-easterly course to head for the
channel between an island and the mainland.
Approximately 25 minutes later, the vessel ran
aground on the shores of the mainland while
still travelling at passage speed. The mate
had fallen asleep in the bridge chair and had
missed the course alteration into the channel.
Investigations revealed that several pieces
of the vessel’s cargo equipment, some
navigation equipment, and the watch alarm
were defective. Historically, the vessel also
suffered a high turnover of senior crew, and
just the day before the accident the mate had
been demoted from the rank of master to that
of mate. Consequently, he had changed his
watch pattern from the master’s 6-12 watch to
the mate’s 12-6 watch. He had managed only
5 hours of sleep in the 24 hours preceding
the accident, and was likely to have been
considerably fatigued when he fell asleep in
the bridge chair.
watchkeepers, but also his circadian rhythm
had been disrupted by the abrupt change
in his watch pattern just before the accident.
In addition to this, he was stressed by his
demotion. Ship owners must recognise that
there are numerous causes of fatigue,
and should take every care to ensure that
the working environment on board does not
contribute to this.
3. A working watch alarm would have ensured
that the mate did not sleep for more than 5
minutes at a time. The MAIB considers that
a dedicated lookout is required during the
hours of darkness. However, had the lookout
needed to leave the bridge for a short time
the watch alarm would have kept the
watchkeeper alert. Watch alarms are
effective only if they work, and they should
never be disabled deliberately.
34 MAIB Safety Digest 1/2012