Lessons Learned on Fatigue, Voyage Planning, Communication

Savannah Ray
Savannah Ray grounding

Published Aug 17, 2016 7:20 PM by The Maritime Executive

The U.S. National Transportation Safety Board (NTSB) has released its annual compendium of marine accidents and the lessons learned from them.

Safer Seas Digest 2015 examines 29 major marine casualty investigations the agency closed in 2015. The 72-page report lists some of the lessons learned from the investigations, such as better voyage planning, the need for effective communications and recognizing the peril of crew fatigue.


Given that inadequate crew/operator rest is a significant factor in accidents among all transportation modes, the NTSB has ranked reducing fatigue- related accidents among the top ten safety improvements on its latest Most Wanted List. Poor watchstanding due to fatigue was responsible for the loss of three fishing vessels described in the report: Pacific Queen, Savannah Ray and Titan

On February 16, 2015, the commercial fishing vessel Savannah Ray grounded on the lee shore of Long Island, Alaska, while traveling in rough seas from fishing grounds off Ugak Island in the Gulf of Alaska to the vessel’s home port at St. Paul Harbor, Kodiak Island, Alaska. The vessel then washed up on the beach about five miles from St. Paul Harbor. The four crewmembers were rescued by a helicopter from Coast Guard Air Station Kodiak. As a result of the grounding, the Savannah Ray was deemed a constructive total loss at an estimated value of $800,000.

The National Transportation Safety Board determined that the probable cause of the grounding of the Savannah Ray was the vessel straying off course and entering shallow water because the captain fell asleep while navigating due to fatigue. Contributing to the grounding was the captain’s failure to use all of the vessel’s available alerting and navigation alarms.

Voyage Planning

The report describes the grounding of the mobile offshore drilling unit Kulluk, owned by Shell Offshore Inc., in heavy weather near Ocean Bay on the eastern coast of Sitkalidak Island off Kodiak Island, Alaska, on December 31, 2012. The Kulluk, under tow by the anchor-handling tug Aiviq, departed Captains Bay near Unalaska, Alaska, 10 days earlier bound for Seattle, Washington. Four crewmembers on the Aiviq suffered minor injuries. The Kulluk sustained substantial damage, including portions of the underwater hull; however, no damage estimate was provided.

The potential hazards facing the transit were known. Although rough weather was anticipated, according to the Kulluk offshore installation manager, “None of us expected to have seas as rough as we had.” 

The NTSB determined that the probable cause of the grounding of the mobile offshore drilling unit Kulluk was Shell’s inadequate assessment of the risk for its planned tow of the Kulluk, resulting in implementation of a tow plan insufficient to mitigate that risk.


Effective communications are essential to safe operations, particularly during emergencies or close maneuvering situations. Before each voyage, vessel crews should develop a communications plan to include both internal (i.e., between watchstanding locations) and external (i.e., between vessels) communications, primary and backup communication systems, a list of stations or vessels using the systems, and procedures for switching between the systems in the event of a failure. Also, before engaging in any operation that involves an increased risk, vessel crews should discuss information expected to be shared during the operation along with emergency procedures. 

Poor internal communications were factors in the American Dynasty and Anna Smile accidents, and a lack of effective external communications played a role in the accidents involving the King Neptune, Mesabi Miner, and Riley Elizabeth tow.

On April 23, 2013, while preparing to enter a graving dock in Esquimalt, British Columbia, Canada, the U.S.-flagged fishing vessel American Dynasty collided with the Canadian Navy frigate HMCS Winnipeg moored nearby, after veering off course following a loss of electrical power and propulsion control. Both vessels and the naval pier sustained extensive structural damage totaling more than $500,000 in repair costs. Six shipyard workers suffered minor injuries.

The NTSB determined that the probable cause of the collision between the American Dynasty and the Winnipeg was the insufficient planning between the American Dynasty’s master and chief engineer regarding vessel arrival procedures and emergency maneuvering and the poor crisis communications between the bridge and the engine room. Contributing to the accident was the status and condition of the American Dynasty’s emergency generator and emergency batteries, which were not prepared to supply power at a critical time.

The report is available here.