The National Transportation Safety Board (NTSB) has released an investigation report on the collision of the passenger and car ferry Cathlamet, with a ferry terminal dolphin that took place last year in Washington, to draw lessons learned.
The incident
On July 28, 2022, about 0814 local time, the passenger and car ferry Cathlamet had crossed Puget Sound and was approaching the Fauntleroy Ferry Terminal in Fauntleroy, Washington, with 94 persons on board when the vessel struck a ferry terminal dolphin. One minor injury was reported. The damage to the vessel was estimated at $10 million, and the dolphin damage estimate was $300,000.
Investigation
NTSB determined that the probable cause of the contact of the passenger vessel Cathlamet with the dolphin at the Fauntleroy Ferry Terminal was the master’s incapacitation, likely due to a microsleep, while the vessel was docking, and the quartermaster not actively monitoring the approach to the ferry terminal and intervening before the contact.
Complacency
The repetitive nature of ferry operations requires operators to sustain a high level of vigilance to prevent complacency. Complacency occurs when operators repeatedly complete a task without consequence, desensitizing them to its inherent risk. As with any repetitive task, individuals become increasingly familiar and comfortable over time with performing the task, which can lead to complacency.
The bridge team on the Cathlamet exhibited complacency through their noncompliance with WSF policies when undocking and docking the ferry. The WSF policy required that the credentialed master or chief mate be present in the pilothouse when undocking the vessel. However, when the vessel departed Vashon Island, the uncredentialed quartermaster was at the helm, and the master was not in the no. 2 pilothouse, as he should have been.
Additionally, WSF policy required that the master be at the helm and the quartermaster serve as a witness when the vessel is docking. As the Cathlamet approached the Fauntleroy Ferry Terminal, the quartermaster did not actively monitor the master as the ferry approached the dock, as required by company policy, when he could have quickly taken the helm if the master became incapacitated.
Adherence to procedures can help combat complacency. In this casualty, watchstanders did not adhere to procedures, which created a single point of failure. The requirement for a second person on the bridge provides redundancy in case a problem arises, such as the master becoming incapacitated. Following the casualty, WSF initiated a review and update of its bridge resource management policies and procedures; the review was still in progress at the time this report published
Lessons Learned
- Watchstanding, Fatigue, and Complacency
Fatigue is often a factor in casualties investigated by the NTSB. Fatigue affects all aspects of human performance, including decision-making, alertness, and reaction time. 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.
In addition, repetitive operations, such as ferry transits—back and forth on the same route—require operators to sustain a high level of vigilance to prevent complacency.
Complacency occurs when operators repeatedly complete a task without consequence, desensitizing them to its inherent risk. As with any repetitive task, individuals become increasingly familiar and comfortable over time.
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.
