Fatigue! – The Root Cause For A Bunker Tanker To Run Aground

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A fuel tanker ran aground in Nunavut in 2014 after its fatigued crew made a wrong turn in Chesterfield Inlet.

fatigue

Incident:

The Bunker tanker was on its way to deliver fuel to a ship waiting at anchorage.  The tanker ran aground as it didn’t follow its charted course.

The bunker tanker was transiting a narrow, shallow inlet in the dark when the Master ordered the helmsman to make a turn to the port side.  The helmsman undertook the order but made a turn to starboard.  When the Master ordered an increase in the angle of the turn to port, the helmsman increased the angle but again in the wrong direction.  The double-hulled tanker ran aground severely damaging its hull and rudder.

Causes:

  • The helmsman incorrectly executed two orders, which caused the vessel to start swinging in the opposite direction from the intended course.
  • The Master continued to repeat the same command without re-evaluating the situation.
  • It was found that the Master and the helmsman did not had enough rest.
  • Ineffective fatigue management on the vessel contributed to the accident.
  • The officer of the watch was not monitoring the vessel’s progress, hence unable to detect the helmsman’s error.
  • The navigation procedure used by the bridge team were not adequate to effectively navigate the vessel.
  • Minimum safe manning levels were not met and the ship was short staffed.
  • Lack of communication amongst the bridge team.
  • The availability of the sea room was limited for the Master to correct the wrong efforts.

Lesson learnt:

  • Effective communication among the crew must be ensured by proper training and compliance.
  • Work allocation among the crew must be simple and well monitored.
  • Proper sleep without disruption must be ensured to the crew.
  • Mandatory training in the principles of bridge resource management must be given for all bridge officers.
  • Every member of the crew must feel responsible for pointing out safety issues.
  • Fatigue management must be made more effective and the crew must have enough time to sleep.
  • Effective measures must be taken to provide lights and buoys in such narrow sea space.
  • Evident navigational procedures must be penned and the crew must be trained accordingly.

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Source: Transportation Safety Board of Canada

1 COMMENT

  1. UN-safe manning levels lead to the need for “fatigue management” as well as poor communications and whatever else the report found lacking. Call IT for what IT is – financial gain with minimum crew!! AND IT will always be that way until more emphasis is put on what actually constitutes “safe manning levels”

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