Think LSR – May 6, 2020
“About four minutes later, the skipper reduced the ferry’s speed to 12kts as it approached the next stop. He then sat back in his chair and closed his eyes. Moments later, the skipper awoke with a start to find the ferry heading straight for a pontoon only 50m ahead. He immediately set full thrust astern and attempted to turn the ferry, but a heavy landing could not be avoided.”
This extract from a report by the UK Marine Accident Investigation Branch (MAIB) describes the few minutes before a collision which resulted in two people being injured and the vessel being taken out of service for repairs – all because the skipper was tired.
AND THIS WAS NOT AN ISOLATED INCIDENT:
On 6 April 2018 a bulk carrier struck the Ergon – St. James Terminal Wharf of the Lower Mississippi River. Fortunately, no one was injured and there was no pollution, but the ship and the wharf sustained damage which cost $6.25 million to put right.
The United States National Transportation Safety Board found that the probable cause of the accident was due to the fatigued pilot’s misjudgment of the turning manoeuvre.
At 0304hrs on 1 July 2017, a bulk carrier and an oil tanker collided in the Dover Strait approximately 5 nautical miles to the west of Sandettie Bank. Both vessels were damaged in the collision but were able to proceed to nearby ports for damage assessment.
The subsequent investigation found that the tanker’s Master had been present on the bridge for over 14 hours and was probably suffering from fatigue, which was likely to have had an adverse effect on his decision making.
In the early hours of 3 December 2016, the bulk carrier Muros ran aground on Haisborough Sand, 8 miles off the Norfolk coast.
The MAIB investigation concluded that the Officer of the Watch’s performance was probably adversely affected by a low state of alertness.
There are many other cases of fatigue causing, or contributing to, serious marine accidents, perhaps most notably the EXXON VALDEZ. This incident lead to the severe pollution of 11000 square miles of ocean and the effects on the local ecosystem, and the local economy, are still being felt some 30 years after the event.
All humans, regardless of race, nationality, age (or rank or occupation) are affected by tiredness and fatigue; no one is exempt. Taking over a bridge watch, or any other safety- critical duty, when over tired is not safe; many watchkeepers will have experienced the sensation of being on the verge of falling off to sleep, either through fatigue or boredom. There are many things that can be done to help prevent this from happening, such as standing up, moving around, getting some fresh air and turning down the heating.
However, if these don’t work, another watchkeeper should be called either to assist or to take over.
Of course, accidents caused by fatigue are not confined to the shipping industry; research conducted in the UK found that fatigue was a factor in 25% of fatal and serious road accidents.
The message is simple: tiredness can kill. The question is: how do we manage fatigue to stop it becoming fatal?
When considering how people become fatigued, we must not just assume fatigue is simply due to long hours and a heavy workload. These factors are certainly direct causes, but other factors also help determine how, and when, people become tired. These include physical fitness, diet, interest in the task they are performing, perceived level of risk, the time of day, the physical environment (i.e. light, noise, vibration, temperature, motion) and sleep disruption due to stress.
STCW regulations do, of course, recognise the dangers of fatigue and specify the hours of rest to be taken by each seafarer. However, this is only part of the solution, and eliminating fatigue as a major cause of accidents requires action at many different levels.
The first level starts at the ship design stage. A person’s ability to sleep, and sleep well, is very dependent on their physical surroundings.
It is therefore important that living accommodation is as stable and free from vibration as possible, and that individuals can control ventilation, temperature and light levels to create the optimum conditions for restful sleep. Design of work spaces is also important to reduce stress and fatigue, as is the design of clothing and equipment.
The second level relies on the adoption of a Company Fatigue Management plan. This is a formal commitment on the part of the company or organisation to reduce the so-called “Sleep debt” and requires the active participation of the company, the Master and the individual seafarer. An example may be as follows:
1. THE COMPANY ENSURES:
- A clear commitment to STCW, MLC and the ISM Code requirements
- Consideration of environmental factors when building, buying or repairing ships
- Adequate rest for joining crews before assuming dutiesAdequate time for proper hand-overs at crew change
- Adequate manning levels for the vessel’s operational schedule
- Voyage length, time in port, length of service and leave ratios that allow time for rest
- The promotion of crew physical and mental health and well-being
- Consistent support to Masters if they decide to stop operations due to unsafe levels of fatigue
2. THE MASTER ENSURES:
- All elements of the company policy are met
- Adequate shore leave, onboard recreation and family contact
- Effective work/rest arrangements and napping opportunities
- Potentially hazardous tasks are scheduled for daytime hours
- Crew education and training to recognise and mitigate fatigue
- Creation of an open, just culture for reporting & dealing with fatigue
- Rotation of high-demand and low-demand tasks
- Accuracy of individual record keeping of hours rested/worked
- Adequate heating, ventilation, air-conditioning and lighting
- Minimisation of noise and vibration in rest areas
- Promotion of a healthy lifestyle and diet
- All problems with the management of fatigue are reported honestly and accurately to the company
3. THE SEAFARER ENSURES:
Adequate personal sleep arrangements
- Aim for deep, uninterrupted sleep 7-8 hours per 24-hour day – Take strategic naps
- Develop pre-sleep routine, e.g. warm shower, light reading – Ensure dark, quiet, cool sleep area and comfortable bed
- Avoid interruptions during extended period of sleep
Adequate diet and fitness
- Avoid alcohol and caffeine before sleep
- Eat regular, well-balanced meals, but eat lightly before bed
- Exercise regularly – it increases alertness both on and off duty
- Accurately record hours of work and rest
- Minimise disturbance of rest/sleep patterns
- Take a break between work periods
- Get sufficient sleep before periods of high activity.
It is recognised that operational and commercial pressures can mean that establishing an effective fatigue management plan may seem easy in theory, but difficult in practice. However, a successful plan can produce very significant benefits – one Canadian company found that in a three-year period:
- The personal injury rate fell by 80%
- The major accident rate fell by 60%
- The staff turnover rate fell by 35%.
All of which saved the company a significant amount of money, and much more importantly, saved individuals the pain and trauma of injury.
It must be stressed that the way to overcome the dangers of fatigue is through awareness, personal responsibility and most of all, imaginative and effective management:
“Fatigue is a common precondition in accidents. The crew of this vessel had been working excessive hours and were all completely exhausted. The skipper’s decision to anchor overnight so everyone could get some rest was sensible, but better working practices could potentially have ensured that they were not exhausted in the first place.”
Stay Safe – Sleep Well – TH!NK LSR!
Data is taken from the UK MAIB Safety Digest 1/2019 & “The Human Element – a guide to human behaviour in the shipping industry” published by the UK MCA. Both publications UK Crown Copyright used with permission.
Peter Chilman, QSE Manager