The Nautical Institute draws lessons learned from an incident where fatigue, poor communication, and procedural lapses led to a fatal accident during heavy weather.
A cargo vessel completed loading and left port in the early morning hours. By about 0400, the pilot departed the vessel, and the Master notified the deck crew to ensure that the berthing stations were secured for the passage; heavy weather was forecast. At 0415 the second officer notified the bridge that all aft lines and machinery were stowed and secured. Five minutes later, the bosun notified the bridge that all was secured at the forward mooring station. In fact, it was not. He had decided to leave the deck to rest, intending to come back later and finish securing.
The vessel encountered increased swell activity, causing it to slam. This woke the Master, and he instructed the officer of the watch (OOW) to reduce speed and alter course to minimise the slamming effects. By midday, the swell had increased. Wave heights were now more than three metres.
After lunch, the chief officer informed the OOW that he was going on deck for a safety check. At around the same time, the bosun and some deck crew, having slept through the morning to recuperate, made their way forward to finish the job of securing the forward mooring station. The vessel was struck by a series of large waves, breaching the forecastle and washing the crew off their feet.
As the chief officer arrived on the forecastle, he found two injured crew members. He raised the alarm and then discovered two other injured crew members further aft. The Master came to the bridge and decided to alter course for the nearest port. The injured crew members were transferred to the ship’s hospital and a request for med-evac was made, but no helicopter was available. Paramedics finally boarded the vessel that evening. Of the four crew members injured, two were declared deceased while another member required emergency surgery. The fourth crew member received treatment on board for minor injuries.
Lessons learned
This report screams ‘fatigue,’ yet this was not brought out in the official report. Why else would the bosun and his team decide not only to mislead the bridge team about the state of the forward mooring station after departure, but also to ‘get some sleep first’ before securing the forward deck?
Fatigue reduces performance in many insidious ways including:
- Reducing problem-solving ability;
- Causing one to forget or ignore normal checks/ procedures;
- Reducing situational awareness;
- Increasing propensity to take risks.
Measures were taken to mitigate the slamming, but at no point was the company’s heavy weather checklist used, nor was access to the open deck restricted.
