Sleep inertia is a silent companion to fatigue and mariners would be well served to be aware of its existence. The Nautical Institute gives this warning in its latest Mars Report, in which a tug pushing two barges hit a lock gate. The master suffered from sleep inertia, which was one of the contrbuting factors.
The Nautical Institute gathers reports of maritime accidents and near-misses. It then publishes these so-called Mars Reports (anonymously) to prevent other accidents from happening. A summary of this incident:
A tug was pushing two steel tank barges loaded with naphtha on an inland waterway. The master had been at the con/helm for several hours before retiring to his cabin for some rest. About 4.5 hours later, a little after 0500, the master awoke and proceeded to the wheelhouse to assume the watch, even though his watch normally started at 0600.
The tow was approaching the eastern end of a lock when the master entered the wheelhouse. The officer offered to take the tow through the lock before turning over the watch, but the captain declined and took the con/helm about five minutes before manoeuvring the tow into the lock. The officer informed the master that he was having trouble communicating via handheld radio with the deckhand, who was stationed on the lead barge.
Also read: Fatigue and weak bridge practices contribute to expensive allision
The master reduced speed on the engines, keeping them “in clutch” ahead to provide steering control as the tow neared the long wall on the north side of the lock. The master’s expectation, from experience, was that they would stop and secure in the lock with the bow of the lead barge about 15 metres from the closed gates ahead. However, on this morning, he was not consistently receiving distance reports from the deckhand because of ongoing trouble with their handheld radios.
As the master was manoeuvring the tow in the lock, the GPS feed to his electronic chart system (ECS) failed, denying him his primary source of speed indication. In the darkness, he had to judge the speed of the tow by watching the illuminated lock wall through his side windows and the lock gates through his forward windows.
With the tug and barges now at a speed of about two knots, the master received a distance report from the deckhand and, realising they were close to the front of the lock, put the engines to full astern. The tow continued to slow, but was still making about one knot when the starboard bow of the forward barge (1 in picture) struck the closed western lock gate.
The official investigation found that the master’s performance and decision making were probably negatively affected by sleep inertia. Sleep inertia can be a factor for thirty minutes or more after waking, especially in demanding situations that require high levels of attention and cognitive demand. Further, waking during a circadian low, such as in this case at 5 am, and partial sleep deprivation, can amplify the effects of sleep inertia.
Also read: Alcohol and fatigue lead to vessel grounding
Advice from The Nautical Institute
- The company operations manual required that a change of watch was not to occur during ‘a critical move’. Examples included operations involving ‘bridges, locks, and docking operations’. The requirement is one of common sense and, in this case, does seem fully justified.
- Fatigue has many negative effects on performance and is notoriously hard to objectively assess by its victims. Sleep inertia is a silent companion to fatigue and mariners would be well served to be aware of its existence.
Mars editor’s note: Accidents rarely if ever happen because of one unsafe condition or unsafe act. This accident is an excellent and clear example of this theory. The master was possibly under the influence of sleep inertia, but several other factors had to conspire to bring about the end result. It was dark, so visual perception was reduced as compared to full daylight. As has been mentioned before in Mars, darkness changes everything. Additionally, communication with the deckhand forward was problematic and the GPS speed input failed at just the wrong time.
Picture (top): General picture of a lock.
This accident was covered in the Mars Reports, originally published as Mars 202234, that are part of Report Number 358. A selection of this Mars Report was also published in SWZ|Maritime’s September 2022 issue. The Nautical Institute compiles these reports to help prevent maritime accidents. That is why they are also published (in full) on SWZ|Maritime’s website.
More reports are needed to keep the scheme interesting and informative. All reports are read only by the Mars coordinator and are treated in the strictest confidence. To submit a report, please use the Mars report form.