Safety Lessons from Marine Incident Investigation (AMSA Report) – No.8 – June 2022
On 19 November 2020, a class 3B fishing vessel grounded on a beach after the master and two deckhands, fell asleep. The investigation identified that there was no clear procedure for standing watch. Fatigue also contributed to the poor decisions made by the crew around who was supposed to be on watch that morning.
In the early hours of the morning, a class 3B fishing vessel that had been fishing for more than 12 hours, was returning to harbour on auto pilot. The vessel had left harbour early in the morning of 18 November and arrived at the fishing ground prior to midday. Crew had finished setting their gear around 1400 and rested until the planned retrieval started at around 1930. Just after midnight on the 19th, the fishing operation was completed and the master set course to return to harbour.
At approximately 0400, the deckhand on watch woke the master to investigate a bilge alarm. The master and deckhand discovered the bilge pump had failed, so the deckhand commenced repairing the pump while the master maintained a lookout. At approximately 0430, the deckhand returned to the wheelhouse to find the other deckhand sitting in the helm chair and the master on the couch next to the galley. The deckhands, each reporting later that they thought the other was going to stand watch, went to their bunks to sleep. The master also fell asleep, under the false impression that one of the deckhands was on watch. At 0620, the master awoke to find the vessel had grounded on sand. The master and crew members abandoned ship onto the beach with no reported injuries. While aground, the combination of grounding, wave action and a flooding tide resulted in damage to the hull and the ingress of seawater. The vessel could not be successfully re-floated.
- The investigation identified the following contributory factors:
- The master did not have a formal watch keeping procedure in place or documented in the vessel’s safety management system.
- The master stated that the normal watchkeeping procedure was that ‘whoever was in the helm chair was on watch’. The Master also stated this had worked successfully for the six years that they had been master on that vessel.
- Given the crew’s extended wakefulness and intermittent rest periods, plus the timing of the bilge pump repair, the crew would have been fatigued. The watch keeping mix-up occurred at a time when each crew member would have been experiencing a circadian low (the body’s natural period of highest sleepiness, usually between 0300-0600). Therefore, the lack of clear decision making regarding who was on watch appears to have been affected by fatigue.
Operators and Masters of fishing operations need to ensure clear and understandable procedures on watch keeping and other safety critical tasks are available within their safety management systems. Research has long established that a fatigued individual struggles with decision making especially after working extended hours (more than 12 hours) and in the early hours of the morning when the individual’s alertness levels are at its lowest. Clear procedures that are familiar to the crew would help to ensure the risks posed by fatigue are appropriately managed.