I always remember people visiting the bridge on an AHTS, wow, huge and such huge couches.
yes thats where we sleep when anchor handling goes wrong…
24 hrs straight, put it on DP, 15min sleep repeat.
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Fatigue does impair judgement you know. How often have you said or heard “I’m too tired to care.”?
There are incompetent people, there are people who seem to lack whatever it is we call judgement, and there are very skilled and competent people who screw up by making the wrong decision or choose what turns out to be the worst of several bad choices. Of course there is always fatigue to cloud the issue.
Well aware of that. Used to be the culture in maritime that it was just a matter of will power which I believed myself until I took a class at the union school which included that topic.
Covered fatigue, sleep cycles and napping and of course sleep inertia.
Almost all of my time at sea - it was a " sleep when you are dead" culture. It was not unusual at all for some mates to do multiple 18-20 hr days in a row on the Chemical ships I sailed on. Not pounding my chest, it was not a good system. The senior officers worked very hard to get another senior mate on board - either chief mate or senior 2nd - this helped a great deal. And the Masters were very good about taking bridge watches for us if we were wiped out from lots of hours on deck.
That may have been why the captain in this case relived the pilot early, just trying to give him a break but the NTSB report doesn’t say, just that it was the captain’s normal practice.
Fatigue not even mentioned in the report, only sleep inertia.
Incompetence, to me, is a functional inability to complete a task to a given standard more times than not. No amount of training will solve incompetence.
Bonehead-ness is a colorful name for human frailty. All humans make errors eventually, no matter how great that human is.
Some years ago I made a survey of the causes of groundings in the particular trade I work in, going back to 1972. No one asked me to make the survey. No one had a vested interest in the answers. I was curious because I noticed how groundings had become largely a thing of the past. In the 1980s groundings happened not infrequently. Now they are unknown. Why? The geography hasn’t changed. BC Inside Passage. Peninsula Inside Passage. Easy to run aground.
I had some after-grounding reports I had conducted myself. I asked some officers I work with to ask captains they knew, who had been at the wheel in other past groundings, to ask them the truth of why they ran aground, in some cases 30 years in the past. So we got pretty honest answers on the QT. Results of the survey, 1972 to present:
14% of the groundings/collisions were caused by fatigue. All of those occurred in the 1980s/1990s. Half of those occurred in the same very small geographic area within a few years of each other in the 1980s, hours after leaving port, following marathon sessions of physical labor far beyond what most readers here can imagine. Not surprising that the officers afterwards fell asleep.
Another 10% of groundings were caused by mechanical failures. 35% were caused by drugs/alcohol, the last of these in 1992. (Note that in three of these cases the captain claimed fatigue, even as he reeked of alcohol).
The other 41% were either incompetence, inexperience, or bad judgement on the part of mate or captain.
Note how fatigue was an issue mostly in the most extreme of circumstances. Once that world of extreme labor died nearly 40 years ago, fatigue stopped being a cause of groundings. Once the USCG drug-and-alcohol rules mandated in 1990 settled-in, that stopped being an issue also.
Which left incompetence, inexperience, or bad judgement on the part of deck officers as the biggest danger. Rising wages solved that problem. When you pay among the best wages in the industry you end up with good quality officers. Hence no incidents for a very long time.
So, knowing that 40 years ago this trade used to work very long hours, beyond the norm of for the industry, and used to do a lot of physical labor, and then sent their officers through labyrinths of islands and channels, and only then 14% of groundings were caused by fatigue, I look askance at fatigue being a major cause of groundings elsewhere today.
Maybe my trade is an outlier. Could be. Or maybe the answers given by officers in other trades after whoopsies sometimes fall into the say-nothing/baffle-with-bullshit/let-your-lawyer-do-the-talking category, which then skews the statistics as to the real causes, leading to a self-perpetuating myth surrounding the contribution of fatigue to whoopsies.
I agree, 6 and 6 is a killer and while I did not work it much the month or so that I was on it continuous totally sucked. The OT was not worth the effort after a few days, and this was in the old days when they could get by with short crews and I was in my 20’s. And in all reality with a 4 on 8 off schedule maybe gets you 6 hours of sleep, not ideal for longevity or being your best especially as the years pile up.
I don’t think that’s the way a NTSB investigation works. In this particular case the interview with the captain is available in the docket. Sleep Inertia is not mentioned. That was the NTSB’s conclusion based on their investigation.
I have no particular issue with the NTSB’s conclusions in this one case. I was talking about the analysis of transportation accidents in general. The NTSB does a very good job researching things, IMO.
Could “incompetence, inexperience, or bad judgement” be the same as fatigue?
Example: I was an OS just starting out, we were in the yards in Singapore. I was out much too late having too much fun before returning for a midnight gangway watch. I took the gangway watch and promptly fell asleep.
Could someone say I fell asleep due to fatigue? Yes, I hadn’t slept before watch. In fact I was asked why I fell asleep on watch and I said I fell asleep because I was exhausted.
Ask me the same question twenty years later. Today I’d say I fell asleep because I was inexperienced and exhibited bad judgement for staying out all day and not resting before watch.
My point is, waiting thirty years to re-ask a question doesn’t make the new answer more truthful. The new answer only reflects the changed perspective of the respondent.
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I did my best to factor it out of the cases I looked at. Also, the histories of the officers before and after the incident could be considered.
Example #1: 25 years ago a mate on one of these vessels T-boned a rock in the BC Inside Passage. His lookout says the mate was on his feet, and referring to the radar. There was a navigational light on the rock. The lookout pointed out the light, dead-ahead, to the mate. Didn’t help. The boat hit the island not far from the light. A simple case of incompetence. Later it came out that he had been fired from a prior job because of incompetence.
You could also say that mate’s incompetence was only the proximate cause. The underlying cause was the company hiring an incompetent mate. (It was his first voyage.) The captain, not knowing the mate, could have taken a less challenging route. So that was an issue too. But the proximate cause was incompetence.
After the grounding the mate claimed there was a “big storm” in the area and that he couldn’t see anything. Despite the fact he was looking at the radar, and the lookout was pointing to the big blinking light, and the log recorded no unusual weather, nor did the weather service note any.
Example #2: A boat was navigating a very narrow channel on the BC IP, back in the 90s. The captain assumed the watch at about 1800. The relieving lookout came up, but the captain told him to go back below–take it easy, watch a video, I’ll call you in a few minutes. So, no lookout.
An hour later later the boat runs aground in the channel. That stretch of channel is straight for the most part, and deep to the edge. Easy to avoid grounding. Look at the radar to stay in the middle. Or look out the window. And why tell the lookout not to come up?
Later the captain claims the boat ran aground because he was looking at the chart. (Not the first time I had heard that particular excuse.) Back in the days of paper charts it was the best excuse. Most chart tables had you looking aft, away from everything else. Nobody could fault you for slacking off if you were looking at a chart. I questioned him carefully. Why spend so much time looking at the chart? Response: I was looking at the chart.
This captain’s subsequent history is illustrative. He left the company and went on to work at two other places, both cruise ship operations with three-watch systems. At one company he ran aground hard on a sandbar on a big western river. At the other company his ship struck a rock (he was not on watch). So there’s a trend there…
My favorite story about the difficulties of getting a straight story about the cause of an accident is the 2006 grounding and sinking of the Queen of the North ferry in BC. The 4th Officer got into an argument with the AB-lookout (who happened to be his ex-wife) and got so distracted he missed a turn, hit an island, sank the ship, and killed two people.
He lawyered up afterwards. In court, his lawyer claimed bad weather and faulty instruments. Court didn’t buy it. Sent the officer to jail. But as far as I know he never changed his story.
So the lookout, who apparently was in the wheelhouse, did nothing to prevent his vessel from grounding? This is a superb example of several cultural/operational failures.
It is the equivalent of a copilot watching the captain reading a book as the aircraft descends into a mountainside and doing nothing other than mentioning the fact that there is a mountain filling the windshield.
So with regards to the NTSB warning…
The three main factors to consider are risk, the rest periods and thirty minute requirement.
In practice there are going to be circumstances where at least one of factors will be compromised. There are limits on how much risk is acceptable so that leaves the rest period and the 30-minute requirement.
The last sentence of the NTSB provides guidance as to what to keep in mind when working with tight margins wrt those two factors.
Mariners should allow time to fully recover from sleep inertia before taking a watch and performing critical duties.
No, it’s not suggested by inference. Did your read the timeline in the report? The Captain woke up at 0500 and immediately went up to the wheelhouse to relieve the watch. Contact with the lock was at 0522.
I’m surprised there was no mention in the report, or yet on here, of the practice of taking over the watch early like this being illegal. It wasn’t an emergency so the Captain wasn’t legally allowed to work more than 12 hours. When you’re working 6x6 coming up early is illegal.
That captain had 30 years experience towing, 20 years on rivers and those waterways as captain or pilot and 10 years of transiting that lock on a regular basis.
So the question is what changed? According to the report:
The captain’s experience in that lock was on boat that backed better (2600 hp vs 2000 hp).There was poor radio communication to the deckhands giving distances and the GPS speed was lost as they entered the lock.
The NTSB report makes the assumption that had the captain been more alert he would have been more likely to have been able to compensate and thus more likely to avoid the damage.
Either way sleep inertia is an added risk and the only one that the captain could reasonable control.
The 6/6 is a factor in that it leaves little room for error and likely some underlaying fatigue but anyone who thinks the NTSB is going to be an ally in that fight is in for a long wait.
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Lol we might as well never sleep if on a 6 and 6 watch, what morons
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That is the only absolutely positive truth based on fact in this entire thread.
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