Master fatigue behind Fiordland Navigator grounding

A SMALL New Zealand cruise vessel that ran aground in Doubtful Sound earlier this year did so because the over-tired master most likely fell asleep at the wheel.

The Transport Accident Investigation Commission reports Fiordland Navigator grounded during a routine turn while on a cruise with nine crew and 57 passengers on board. Several people received minor injuries, and the vessel was moderately damaged.

The crew responded well to the emergency, TAIC found, safely evacuating passengers to Deep Cove, then to Te Anau that evening. The vessel returned to Deep Cove that night.

“The master almost certainly fell asleep at the controls due to workload-induced fatigue. The master was very likely fatigued from long work hours, which weren’t monitored or effectively managed. The operator’s safety system didn’t track actual rest hours or properly identify or mitigate fatigue risks for sole-charge masters,” TAIC found.

“While the master had a valid medical certificate, medical fitness isn’t just a one-time check. There was no system to assure ongoing medical fitness during the two-year certification period. The vessel’s Senior Launch Master, responsible for safety procedures, had too much work to effectively oversee fatigue management.” 

The Commission identified four key safety issues:

1. Medical fitness standards: Seafarers may not fully understand their responsibilities to report medical conditions affecting their fitness for duty. TAIC recommends that Maritime NZ improve awareness and enforcement of medical fitness standards.

There is no need for TAIC recommendations on three further issues because the vessel's operator RealNZ has mitigated the risks:

• Fatigue management: The operator’s fatigue-management system didn’t prevent fatigue. Operator has updated its fatigue policy, introduced new training and monitoring measures, and improved work-hour tracking.
• Sole-charge master risk: RealNZ hadn’t properly identified or mitigated the risks of having a sole-charge master. Operator has added a second person to the wheelhouse during navigation and reinstated the Master’s Assistant role. 
• Safety management oversight: The person responsible for day-to-day safety oversight was overburdened, making risk management less effective. Operator has created a Maritime Resource Planner role and adjusted management responsibilities to improve oversight.

TAIC said key learnings from the incident are:

• Medical fitness should be continuously monitored, not just at certification.
• Workload and actual rest hours must be properly tracked and managed.
• Sole-charge masters pose a safety risk if fatigue is not addressed.
• Safety systems need enough staff and resources to function effectively.