News conference for the release of
the Marine Investigation Report M16P0378 (Nathan E. Stewart)
Kathy Fox, TSB Chair
Glenn Budden, Investigator-in-charge
Vancouver, British Columbia
31 May 2018
Check against delivery.
On the evening of October 11, 2016, the U.S.-registered tug Nathan E. Stewart departed Ketchikan, Alaska, bound for Vancouver, British Columbia. The tug was pushing an empty tank-barge, the DBL 55, and together the two vessels formed what's known as an articulated tug-barge unit.
Just after 1 a.m. on the morning of October 13, the tug-barge unit ran aground at the entrance to Seaforth Channel, approximately 10 nautical miles west of Bella Bella. After several hours of pounding from the waves, the tug's hull breached, and it released over 110 000 litres of diesel fuel before eventually sinking later that day.
The TSB learned early in the investigation that the watchkeeper on duty, who was alone on the bridge when the vessel ran aground, had unintentionally fallen asleep and missed a planned course change.
Today we are releasing our investigation report into this occurrence and making two recommendations. First, we are asking that watchkeepers receive mandatory education and awareness training with respect to minimizing the risks of sleep-related fatigue. Our second recommendation is to require that vessel owners implement comprehensive fatigue-management plans, tailored specifically for their individual operations.
The TSB recognizes the public's significant concern with the risk of oil spills along Canada's coastlines, just as we acknowledge the spill's threat to the natural resources within the traditional territories of the Heiltsuk First Nation—resources they depend on for their traditional activities, their economy, and their cultural identity. And although a study of spill response along the entire West Coast is outside the TSB's mandate, we did review the immediate spill response and salvage operations for this occurrence and noted an opportunity for future improvement.
I'll talk more about some of these issues shortly, but first I'll turn things over to the Investigator-in-charge, Glenn Budden. He'll walk you through the details of what happened that night and into the morning, and explain what we know about the underlying causes of the accident. Glenn?
Thank you, Kathy.
At 11 p.m. on the evening of October 12, about 2 hours before the occurrence, the Nathan E. Stewart's second mate arrived in the wheelhouse to take over navigational watch duties from the master. The master then went to bed, leaving the second mate alone on the bridge.
The tug-barge unit was transiting through an area that is part of the Inside Passage, a route that weaves through the islands along BC's coast. Canadian regulations require crews of vessels transiting this area to be assisted by a Marine "pilot"— a highly experienced mariner with a good "local knowledge" of the waters—or … for those crews to include a watchkeeper holding a valid pilotage exemption, or waiver.
The master was the only watchkeeper on the Nathan E. Stewart who held a valid pilotage waiver for the Inside Passage. In other words, once he went to bed, the vessel was no longer compliant with the waiver requirements. Moreover, the master's departure left the second mate as the sole person on the bridge—even though Canadian regulations and company procedures require at least twot people on the bridge "during hours of darkness."
Already tired at the start of his shift, the second mate had likely been awake for about 11 hours—mainly because, like the rest of the watchkeepers, he'd spent the previous two-and-a-half days working a challenging "6-on, 6-off" schedule: alternating periods of six hours on duty, followed by a six-hour rest period. This type of schedule is well-known for disrupting the normal sleep-wake cycle, and for limiting opportunities to obtain sufficient "restorative" sleep. The numerous deficiencies of this schedule have been documented by various studies and experts internationally.
As the second mate began his watch, he made his workstation comfortable by adjusting the bridge chair and the lighting, turning up the heat, and putting on some light music. Shortly after midnight, he made one course alteration, but then fell asleep … and the tug-barge unit's course and speed went unchanged for the next 46 minutes, until it struck and grounded on a reef.
Following the grounding, many local, provincial, and federal marine resources and agencies responded. These included the Joint Rescue Coordination Centre, members of the Heiltsuk First Nation, the Canadian Coast Guard, and the RCMP. Heiltsuk vessels, in particular, were among the first on scene, arriving at first light, offering assistance, and alerting others in the community to the situation.
The Nathan E. Stewart, meanwhile, stuck on the reef, was subjected to repeated pounding and wave action. After several hours of this, the hull breached, eventually releasing over 110 000 litres of diesel fuel. By 9 a.m., the vessel's stern had sunk below the waterline, and by 7 o'clock that evening, it completely filled with water and sank.
The empty barge broke free and was subsequently towed away.
As for the response to the spill and the salvage operation, the TSB's investigation noted two things in particular: first, that during the initial response some agencies were not familiar with the incident command system, which created confusion about the roles and responsibilities of all responding agencies, and about who had final authority. Second, that after everything was finished there was no coordinated or comprehensive evaluationt by those involved—meaning that an opportunity was missed to find out what elements could be improved in future … should there be a next time.
Now, to discuss what steps the TSB would like to see taken, I'll turn things back to Kathy Fox.
Sleep is a fundamental biological need, and when that need is not met the result is fatigue.
At the TSB, we have identified fatigue as a causal or contributory factor in numerous marine investigations, going back to 1993. For example, in this occurrence, the watchkeepers of the Nathan E. Stewart had been working this 6-on 6-off shift schedule for two-and-a-half days prior to the grounding. Although this schedule provides opportunities for sleep, the second mate was unable to nap during the afternoon rest periods—like most people. This, combined with the sleep-inducing conditions on the bridge and the fact that he was alone on the bridge, resulted in him inadvertently falling asleep while on watch.
Although this type of shift schedule has been called into question by various international studies and experts, it continues to be used throughout the marine industry. There is therefore a compelling need for operators and watchkeepers to be aware of—and to recognize and address—the factors that contribute to fatigue.
Transport Canada's Marine Personnel Regulations are intended to mitigate the risks of fatigue by requiring minimum rest periods over a given time period. More, though, must be done.
It's hard enough to work a 6-on 6-off shift for days on end without getting a "good night's sleep." It's harder still to do it without the means to recognize and combat the fatigue that this schedule inevitably generates.
If watchkeepers have a better understanding of what fatigue is, the factors that cause it, and of the practical actions that can be taken to eliminate or minimize its effects, there may be a significant reduction in the number of fatigue-related marine occurrences.
That's why the TSB is recommending that Transport Canada require "that watchkeepers whose work and rest periods are regulated by the Marine Personnel Regulations receive practical fatigue education and awareness training in order to help identify and prevent the risks of fatigue."
So that's the first step: education and awareness training. But it is only the first step. Because transportation operators—the people who have the primary responsibility for managing the safety risks within their own operations—also need to have a clear, well-thought-out plan to manage fatigue.
In Canada's railway industry, fatigue has been studied and recognized as a risk for over three decades. Canada's aviation sector has also begun taking steps toward improving the management of these risks. More steps, however, are needed to effectively and reliably prevent fatigue in the marine industry.
What's required are formal fatigue-management plans—plans that are specific to the risks and challenges faced by each operator's unique environment and circumstances. This means going beyond current regulations and developing concrete strategies and scheduling practices that incorporate modern principles of fatigue science.
That's why we are recommending that Transport Canada require vessel owners whose watchkeepers' work and rest periods are regulated by the Marine Personnel Regulations to implement a comprehensive fatigue management plan tailored specifically for their operation, to reduce the risk of fatigue.