Lessons learned: Crew fatigue leads to improper handover follow-up

The incident

A time-constrained handover took place on board a tanker at anchor the evening prior to a planned canal transit. The off-signing crew of 21, who had been on board for 11 months, were relieved by a complement of 14; the remainder scheduled to join at the next port. Over the following weeks the on-signing Master and Chief Officer identified almost 60 serious defects and material deficiencies, none of which had been handed over by the off-signing crew.

During further correspondence CHIRP sighted documentary evidence of almost 60 defects, many of which had serious vessel safety implications, including:

• Incorrect ECDIS safety settings for ocean, coastal and port approaches.
• The port and starboard anchor shackle marks were missing.
• The rescue boat had not been launched during the past three months. The rescue boat should be launched every month or, at a minimum, every three months.
• There were no entries for maintenance or usage in the Compressed Air Breathing Apparatus (CABA) compressor logbook.
• Oil droplets and fatty deposits were observed on the galley exhaust fan vent grille (which exhausted onto the accommodation deck) and on the deck below the vent.
• There was no formal numbering system for the firefighting equipment.
• 75% of personal oxygen analyser sensors were unserviceable.
• All the chemical Draeger tubes had expired.
• Almost all the Chief Officer’s files located in the cargo control room were incomplete.
• There were no gas reading records for the cargo tanks which has been recently inerted.
• Several of the indicating sensors for the cargo valves did not show the correct value.

According to CHIRP, the management company should ensure that handovers occur in a suitable port with adequate time for an effective exchange of information so that the incoming Master is fully apprised of the vessel’s material condition. Handovers normally follow a procedure set out within the SMS including, but not limited to:

• A report on the officers and crew, including their experience, highlighting their time on board, relief schedules and any health matters.
• Inspection of trading certificates including those where a survey is due.
• Any conditions of class or memos.
• Bridge equipment and navigational documentation, passage plans, chart correction status, and navigational warnings.
• The current cargo status including stability information.
• Critical items of equipment that are due for maintenance or inspection / survey must be highlighted.
• Status of bunkers, fresh water and victualing supplies.
• Master’s PMS job status, cash, and password control.
• A full tour of the ship with the outgoing Master including the engine room.

It is also crucial that the incoming Master understands the navigational, mechanical, structural, safety and pollution risks associated with the ship before signing the official logbook to accept responsibility for the vessel’s safety. In this case the Master spent two weeks identifying these defects and is commended by CHIRP for the diligent and proactive way they rectified the material defects and crewtraining deficiencies identified.

To ensure consistency CHIRP strongly recommends that every vessel’s SMS sets out a comprehensive procedure
based on formal risk assessment. The timing and location of handovers must be carefully planned by the shore
management team and adequate time scheduled for them to take place

says CHIRP.

Furthermore, on-signing crews should be well rested prior to the handover so that they are fully able to digest the information presented. Whole-crew changes are not recommended: it is best practice to stagger crews to maintain continuity of knowledge. Changing the Master and Chief Officer together is unwise and potentially unsafe.

The number of faults reported further  indicates that the offsigning crew did not do all that was expected of them, which is probably the result of crew fatigue after so long at sea. This could reasonably have been foreseen by a more proactive shore management team.

Human factors

• Fatigue: (Cognitive) – Don’t focus on trivial problems and neglect the more important ones.
• Fatigue: (Behavioural) – Don’t ignore normal checks and procedures; beware an increase in mistakes and carelessness.
• Culture – Applies to individuals and the whole organisation.