FOLLOWUP: Federal investigators blame ferry Cathlamet’s Fauntleroy crash on ‘fatigue and complacency,’ saying the captain apparently briefly fell asleep

(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

13 Replies to "FOLLOWUP: Federal investigators blame ferry Cathlamet's Fauntleroy crash on 'fatigue and complacency,' saying the captain apparently briefly fell asleep"

  • DRW October 12, 2023 (3:09 pm)

    Dolphin 1 Cathlamet 0

  • Brandon October 12, 2023 (3:20 pm)

    How much money and resources went into an NTSB investigation that concluded with an 18-page report on a dude falling asleep and not following best practices that took FOURTEEN MONTHS? Inquiring minds would like to know.

    • Flivver October 12, 2023 (4:08 pm)

      Brandon. Here in the real world that’s how long THOROUGH investigations take. If they weren’t 100% thorough in investigating ALL the facts and data and confirming ALL the facts and data they’d be accused of “rushing the investigation”. This is the real world and not TV where everything is solved in one hour.

      • Brandon October 12, 2023 (4:42 pm)

        Annnnnd yet the State ferries were able to complete their own investigation it 6 months prior. Curious how 3 million more (37%) in damages appeared the longer the feds looked at it. Same incident. Clearly the WSF rushed it (sarcasm).

    • Marcus October 12, 2023 (4:21 pm)

      As much money as it takes and time.  These things take time and it is best to be patient.  Takes time to determine if it is mechanical or human error.  Rash judgements are not acceptable.

  • WS Res October 12, 2023 (4:09 pm)


  • Brendan October 12, 2023 (4:44 pm)

    This other B agrees w/ Brandon – seems like a significant waste of time, resources and $$$ all around. Inquiring minds would also like to know what happens next with ol’ Master Sleepyhead?!? Sounds like they copped out, got out and clammed up before having to accept any real responsibility for their actions. What kind of repercussions (monetary or otherwise) can they expect for such a massive mess up?

    • Flivver October 12, 2023 (6:17 pm)

      Brendan/Brandon. If it was such a waste eagerly awaiting hearing you demand local/state/federal investigators not waste time with thorough investigations and save time by guessing/speculating. As far as going after employees who cause damage be careful what you wish for. If you have an accident at work guarantee you won’t happily give up all your money and bankrupt yourself.

      • Baaron October 13, 2023 (8:46 am)

        it’s like the Bs know nothing about insurance or how companies have been mitigating risk for hundreds of years. i don’t think it’d be hard to assume that they’re the same folks that think OSHA is overbearing or believe any deregulation is a good thing.

  • pauline October 13, 2023 (12:07 pm)

    Whelp that’s capitalism (keep it moving with limited paid sick time and such, expensive health care). Who knows the individual’s shifts, their capacity/shortage of staff to rotate, individual’s health condition, burnt out, overworked, etc. glad it thoroughly investigated for any structural changes..

    • Rhonda October 13, 2023 (2:04 pm)

      Uh, pauline, the Washington State ferry system is a 100% Socialist endeavor: state-owned, state-run, and state-funded. The only Capitalist thing about it are the vending machines.

  • Elle October 13, 2023 (6:52 pm)

    I think it’s a little easy to blame it on “capitalism” – someone responsible for the safety of so many passengers should not be asleep at the wheel, and it’s his responsability to take time off if he’s not up for the job. Looks like Ferry workers have very decent sick leave, health and vacation benefits. 

    • WS Res October 13, 2023 (7:29 pm)

      When the system is understaffed, there’s a lot of pressure not to call out even if you really shouldn’t work.

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