(Photo by Mark Dale, July 28, 2022)
Thanks for the tips. Fourteen and a half months after the state ferry M/V Cathlamet hit an offshore structure at the Fauntleroy terminal, the National Transportation Safety Board has announced the results of its investigation. First, here’s the NTSB summary:
Fatigue and complacency led to a Washington State Ferries passenger and car ferry striking a mooring structure, or dolphin, at a Seattle ferry terminal last year, the National Transportation Safety Board said Thursday. The contact resulted in $10.3 million in damages to the vessel and $300,000 in damages to the dolphin.
The Cathlamet had crossed Puget Sound with 94 people on board and was approaching the Fauntleroy Ferry Terminal on July 28, 2022, when it struck the ferry terminal dolphin. One minor injury was reported.
The master did not take any action to correct the ferry’s course, slow down or sound the alarm before the contact. He also did not recall what happened and seemed unaware of how the ferry ended up striking the dolphin. Investigators found these events were all consistent with incapacitation from a microsleep, a brief period of sleep lasting a few seconds, due to fatigue.
“Fatigue affects all aspects of human performance, including decision-making, alertness, and reaction time,” NTSB investigators said in the final report. “Mariners should understand the performance effects of sleep loss and recognize the dangers of fatigue, such as microsleeps. When affected by fatigue, mariners should arrange for a qualified watchstander to serve in their place and avoid being on duty when unable to safely carry out their responsibilities.”
The NTSB also found the Cathlamet bridge team exhibited complacency by not complying with Washington State Ferries’ policies when undocking and docking the ferry. The Cathlamet quartermaster did not actively monitor the master as the ferry approached the dock, as required by company policy. Had he done so, he could have quickly taken the helm when the master became incapacitated.
“Complacency occurs when operators repeatedly complete a task without consequence, desensitizing them to its inherent risk,” the report said. “To combat complacency, 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.”
The full 18-page investigation report is here. It includes this:
Coast Guard Investigators interviewed the master on the day of the casualty. When asked if he felt rested when he arrived at the vessel on the morning of the casualty, the master said, “Well, I don’t know if I’d call it 100% rested … I mean, it was hot out, very hot, you know, trying to sleep.” (At the time of the casualty, there was a heat wave occurring in the Seattle area.) The master informed investigators of a family member’s medical condition and overall health, which had been deteriorating, and that the situation had been bothering him. The master told investigators, “I got engagement, and the next thing I know I hit, I hit the dolphin. That’s all I know.”
The master retired from WSF the day after the casualty, surrendered his Coast Guard credential, and would not provide any additional information to investigators.
Washington State Ferries released its own report back in March (WSB coverage here), as the repaired ferry was finally returning to service. The federal report lists a higher cost ($10.6 million) for the ferry and structure damage than WSF cited ($7.7 million) back in March
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