NTSB: Pilot fatigue led to $6 million Louisiana wharf strikeAug 27, 2019 10:11 AM
Shandong Fu En, shown underway in a photo from the NTSB report, was holed below the waterline when it hit Dock 1 at the Ergon-St. James Terminal in Convent, La.
The plan for turning the loaded bulk carrier was relatively straightforward: With help from three assist tugboats and the fast Mississippi River current, Shandong Fu En would spin almost 180 degrees off the dock for an outbound transit.
It didn’t turn out that way. Instead, the 751-foot ship drifted downriver nearly broadside to the current. Attempts to accelerate the counterclockwise rotation weren’t successful, and the ship’s bow struck a wharf across the river in Convent, La. The incident occurred at 0637 on April 6, 2018, at mile marker 160.7.
No one was injured, but forward sections of Shandong Fu En flooded and the wharf required nearly $6 million in repairs. The ship cost nearly $250,000 to fix.
Investigators with the National Transportation Safety Board (NTSB) determined that the onboard pilot from New Orleans-Baton Rouge Steamship Pilots Association (NOBRA) slept only four hours during the previous 36. The agency cited the pilot’s fatigue as the probable cause of the incident.
“The (tugboats) could have been positioned differently and the full-astern engine orders could have been executed earlier to keep the bulker from drifting,” the NTSB said in its accident brief. “The pilot’s limited sleep and the fact that he was nearing the end of an eight-hour shift increased the likelihood that fatigue affected his judgment … in challenging high-water conditions.”
The Carrollton Gauge located downriver in New Orleans registered 14 feet on the morning of the incident, which is considered high but not flood stage. The current was running nearly 4.7 knots, necessitating three assist vessels to hold station as the Hong Kong-flagged Shandong Fu En loaded coal at the Convent Marine Terminal. The NOBRA pilot boarded the ship at midnight on April 5 as another precaution during high water.
The 1-year-old ship got underway at 0628 on April 6 with the pilot’s order to move the bulker forward, roughly 150 feet from the pier. The maneuver provided additional space between the ship and a derrick barge moored behind it. About a minute later, the ship’s heading began moving to port.
Over the next five minutes, the heading inched further to port as slowly as 5 degrees per minute and as fast as 37 degrees per minute. The pilot increased power astern to increase the rate of turn but with limited effect. He ordered dead-slow astern at 0634, followed by slow astern a minute later. Within 30 seconds he issued two more orders, finishing on full astern.
“At 0636:26 … the Admiral Jackson (tugboat) captain radioed, ‘…you’re pretty close right here,’” the report stated. The pilot responded he was “backing all I got.” Less than 15 seconds later, the ship’s bow struck Dock 1 at the Ergon-St. James Terminal.
Shandong Fu En underwent a survey at anchor 13 miles downriver. The ship had hull penetrations below the waterline, including a 6.5-by-2-foot crack and three 6-inch-diameter punctures. Damage to the terminal was mainly limited to mooring dolphins and walkways.
The pilot aboard Shandong Fu En had 18 years of experience, with eight years on the Mississippi River. He had performed similar maneuvers many times, including during high water. He also had completed identical maneuvers from the Convent Marine Terminal.
But the incident voyage was different in at least one notable way: The pilot had slept only from 1400 to 1800 on the day before the accident. He boarded Shandong Fu En eight hours after his previous assignment and had been on watch for 12 of the previous 24 hours, which approached operational limits imposed on the NOBRA pilots.
The effects of fatigue, like a wasting deck plate, often are not immediately visible. However, it has been shown repeatedly over the years to hinder performance. Delayed reaction times, reduced alertness and difficulty processing information are some obvious signs.
“It can, therefore, degrade a person’s ability to stay alert and attentive to the demands of safely controlling a vessel,” the NTSB reiterated.
The NOBRA Board of Examiners changed some internal rest policies in the aftermath of the Shandong Fu En incident. As of Jan. 17, its pilots are required to have at least 12 hours of rest between “turns,” and they are limited to no more than six consecutive hours on the bridge when dispatched. Other changes limit certain undocking maneuvers to daylight hours.
Capt. Steve Hathorn, president of NOBRA, said he was surprised the NTSB cited fatigue as a leading factor in the case. He said NOBRA’s requirement for eight hours rest between turns exceeds Coast Guard and industry standards.