Fatigue and complacency can lead to big problems when it comes to workplace safety. A 2022 maritime incident that resulted in an injury and millions of dollars in damages is a perfect example of what kind of damage can come from these two safety issues.
National Transportation Safety Board (NTSB) investigators learned that a ferry captain’s severe lack of sleep along with the bridge crew’s complacency toward safety procedures led to a minor injury and $10.3 million in damages when the vessel struck a mooring structure at a terminal.
Ferry strikes terminal structure at 18 mph
On July 28, 2022, the Washington State Ferries passenger and car ferry Cathlamet was approaching the Fauntleroy Ferry Terminal in Fauntleroy, Washington with 94 people on board.
As the Cathlamet was being maneuvered toward the terminal’s dock, the vessel’s quartermaster “felt that something wasn’t right.”
“There should have been more of a slowdown,” he told investigators. “It … should have taken longer to the dock.”
A series of adjustments moved the Cathlamet rapidly toward, instead of away from, a mooring structure called a terminal dolphin, which was about 35 feet south of where ferries would dock at the terminal. The ferry struck the terminal dolphin at 15.7 knots, or 18 mph.
Passenger clings to railing as deck collapses beneath him
At the same time, a passenger saw that the ferry was about to strike the terminal dolphin and started to move toward the rear of the vessel. When the ferry struck the terminal dolphin, the area where he was just standing collapsed from the impact. He grabbed onto a railing and hung on, which prevented him from falling to the damaged deck below.
As the deck collapsed, another part of the deck structure folded onto the car deck and penetrated the interior of a parked car, just missing an occupant in the vehicle’s driver’s seat.
After striking the terminal dolphin, the ferry continued to move forward toward the shore where other vessels were anchored. The quartermaster told investigators that the captain – actually referred to as the “master” in reports – who was controlling the ferry at the time of the crash, looked at him and asked twice, “What happened?” The quartermaster, realizing that the ferry was still moving toward other vessels, told the captain to back out. He had to repeat the order two more times before the captain took action.
One passenger received minor injuries. Damage to the Cathlamet was estimated to be $10.3 million. Considering the near-misses resulting from the crash, the situation could have been much worse.
No evidence of drug use, distractions
The captain’s post-crash drug and alcohol tests were negative and distractions, such as cell phone use, were also ruled out.
A review of the captain’s work/rest history revealed that he had been sleeping five to six hours per night before the crash. Crewmembers testified that the captain was always tired in the morning. The captain admitted that he’d been getting poor sleep because of an ongoing heat wave and a family member’s medical condition. He told investigators that he couldn’t remember much of what happened leading up to the incident.
The captain retired from Washington State Ferries the day after the crash, surrendered his Coast Guard credentials and wouldn’t provide any additional information to investigators.
Investigators also found that the Cathlamet bridge team was complacent toward safety protocols by not complying with company policies when undocking and docking the ferry. The quartermaster failed to actively monitor the captain as the ferry approached the dock like he was supposed to. Had the quartermaster done as company policy required, he could have quickly taken over the helm and prevented the crash.
To prevent this kind of incident, NTSB investigators said that both worker fatigue and complacency must be addressed.
Fatigue leads to uncontrolled periods of ‘microsleep’
Individuals typically require seven to eight hours of sleep per night to avoid the effects of fatigue, the NTSB report said.
Further, “a cumulative sleep debt can accrue over the course of several days when an individual consistently receives less than 8 hours of sleep.”
The captain in this case was fatigued because of an accumulated sleep debt. What sleep he did get was of poor quality because of the effects of the heat wave and his concerns over a family member’s deteriorating health.
Fatigue causes decreased:
- attention
- reaction time
- vigilance, and
- decision-making.
It also makes individuals susceptible to microsleep, brief periods of sleep lasting for a few seconds. A moment of microsleep is likely what caused the captain to lose control of the ferry.
The NTSB advised that mariners who are affected by fatigue “should arrange for a qualified watchstander to serve in their place and avoid being on duty when unable to safely carry out their responsibilities.”
Likewise, fatigued workers in any industry should make arrangements with company management to address the issue and ensure the safety of themselves and co-workers.
Combat complacency with focus on procedures
Ferry operations involve a lot of repetition. That repetition can lead to complacency, which the NTSB defined as repeatedly completing a task without consequence, which desensitizes crewmembers to the task’s inherent risks.
“As with any repetitive task, individuals become increasingly familiar and comfortable over time with performing the task, which can lead to complacency,” according to the NTSB report.
The quartermaster’s failure to actively monitor the captain as the ferry approached the dock was due to complacency, NTSB investigators found.
What’s the best way to combat complacency? Tell workers how important procedures are.
The NTSB said “operators should comply with procedures, such as operating checklists, that are in place to prevent single points of failure, and companies should train operators on the importance of following procedures.”
