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Probe: Wrong turn, lack of awareness were factors in ferry crash

Feb 25, 2014 01:25 PM

Eight minutes into a journey between neighboring islands, the inexperienced second mate steering the Washington State Ferries vessel Hyak became concerned about a nearby motor yacht.

The captain directed him to “come to port and sound the whistle if necessary” to avoid a close-quarters situation while overtaking the smaller craft. According to an investigative report, the second mate instead moved the rudder to starboard — toward the motor yacht — for four long seconds.

The captain seized the controls and tried to avoid a collision, but it was too late: the 382-foot ferry slammed into the 29-foot motor yacht Tasya about 20 seconds later.

The accident occurred at 1338 on Sept. 13, 2013, near the intersection of the Harney and Upright channels in the San Juan Islands.

“The Board of Inquiry determined that the root cause of this incident was human error due to lack of situational awareness,” according to the report issued by Washington State Ferries, which deemed the accident avoidable.

“Specifically, the captain’s lack of situational awareness in combination with the second mate’s inexperience at the helm of the MV Hyak resulted in an in-extremis situation and eventual collision.”

Hyak left Lopez Island en route to Orcas Island at about 1330 on Sept. 13 with the second mate at the helm. The captain identified several vessels on the ferry’s likely path through Harney Channel, including a tugboat, a sailboat and Tasya.  

The captain arranged a port-to-port passage with an approaching tug and barge and directed the second mate to pass between the sailboat and Tasya, which was underway at about 6.5 knots, the report said.

After making those passing arrangements, the captain “returned to the radar and was looking down into the radar for approximately one minute before the incident with the MV Tasya,” the report said.  

Less than a minute later, at about 1338, the second mate warned that the ferry was increasingly close to the motor yacht. The captain told him to come to port, but he performed the opposite rudder action.

Investigators determined the second mate understood her directions but applied the wrong rudder direction, the report said. They determined the captain’s rudder directions were too vague.

The ferry slammed into Tasya’s port quarter, breaching its hull. The vessel immediately began taking on water, and its lone occupant was rescued by a nearby good Samaritan vessel. The yacht sank later that afternoon while being towed to shore.

The ferry system convened a board of inquiry the day of the accident to investigate what happened. The board determined the captain “was overly reliant on radar observation and failed to monitor vessels on her intended route.” She “did not use all available means to ascertain the accurate location of the MV Tasya and take necessary actions to avoid collision.”

She made statements to the board suggesting she believed the collision took place in a different part of the channel than it actually did.

Investigators found that the “V” maneuver performed upon departure from Lopez Island Terminal created a blind spot that might have prevented the captain from seeing Tasya. The yacht was not reported by a lookout.

The second mate started working for Washington State Ferries nine months before the accident, and he served as a helmsman on other routes offered by the ferry system. He was training on the day of the accident.

Based on its findings, the board of inquiry issued six safety recommendations. They included better training, development of a refresher training course for officers involved with navigational watch and better definition of some job duties. The board suggested installing voyage data recorders on all Washington State Ferries vessels.

“We are reviewing all of the recommendations and formulating next steps,” ferry system spokesman Joy Goldenberg said in late December. “As for the bridge management team training, it is being scheduled as funds and resources allow.”

The captain and the second mate were placed on paid leave following the accident. A final decision on the employees’ job status was expected in early 2014.
 

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