Ferry master ‘almost certainly fell asleep’ before Pentland Firth grounding
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The master of the Pentland Firth ferry Alfred “almost certainly fell asleep” before the vessel ran aground on Swona, causing injuries to more than 40 passengers and crew, an investigation has found.
Fatigue led to “loss of awareness at a critical point” during a crossing between Gills Bay and St Margaret’s Hope in July 2022, according to a report by the Marine Accident Investigation Branch (MAIB).
The report also said the roll-on/roll-off ferry had been “routinely passing too close to land” and identified a “lack of assurance that procedures were being followed” by the vessel’s operator, Pentland Ferries.
There were more than 80 people on board who had to be transferred into two RNLI lifeboats – from Orkney and Thurso – and taken back to the mainland.
CCTV footage released by MAIB shows the impact when the ferry grounded on the east coast of Swona in calm conditions at around 2pm on July 5, 2022.
The impact caused injuries to 41 passengers and crew as well as damage to Alfred’s port bulbous bow and almost all the vehicles being transported on board, MAIB said.
The investigation found the master may have fallen asleep for about 70 seconds, leaving “insufficient time for him to take action to prevent the vessel grounding”.
Andrew Moll, chief inspector of marine accidents, said: “Lots of safety action has been taken as a result of this accident and I am encouraged by the actions taken by Pentland Ferries to address the issues raised in this report. However, this accident offers a wider opportunity for lessons to be learned across the maritime industry.
“Alfred’s master routinely operated very close to the coast, leaving little margin for error when they found themselves in an unsafe situation.
“Regardless of the type of vessel you are operating, it is critical that a safe passage plan is made and that it is followed. Always allow sufficient sea room to enable action to be taken in good time if things are not going to plan.
"On the afternoon of July 5, 2022, the master almost certainly fell asleep and allowed the ferry to swing towards land. Crew should always be sufficiently well rested when coming on duty.
"Finally, this case highlights the importance of management assuring themselves that plans and procedures they have put in place are actually being followed. If you have management oversight of a vessel or maritime operation, ask yourself; do I know that our crews and frontline staff are following our procedures, and are our plans fit for purpose in a real-life emergency situation?”
A series of recommendations have been made to the Maritime and Coastguard Agency. These include ensuring that passage plans are available during inspections/surveys and issuing guidance to the UK domestic passenger fleet on the need to secure heavy objects.
A recommendation has also been made to Pentland Ferries to ensure that it captures passenger details and injuries post-accident.
Pentland Ferries’ managing director, Helen Inkster, said: “We very much welcome the publication of the MAIB report and continue to digest its contents.
“We stand by the premise of the report, which is not to assign blame or liability but rather to ensure future accidents across the marine industry are prevented.
“While we will never be complacent, we are satisfied that all the actions that could be taken by Pentland Ferries to ensure passenger safety have already been taken. We will always ensure that our vessels have detailed procedural plans, the right people, and rigorous training regimes in place.”
After the accident, the ferry refloated on the rising tide and continued to St Margaret’s Hope under its own power. There was no pollution, but the vessel was withdrawn from service for repairs.
In September 2022 it was reported that passengers who were injured on the Alfred were planning to take legal action.
Pentland Ferries operates daily services between Gills Bay in Caithness and St Margaret’s Hope in Orkney. The £14 million MV Alfred made its inaugural voyage in October 2019.
On the issue of fatigue, the report said: “The master was very familiar with the route and had worked on Alfred and its predecessor Pentalina for over 20 years, completing more than 20,000 trips between the north coast of Scotland and the Orkney Islands. On the day of the accident, as he had done many times before, the master adjusted the vessel’s track to take it close inshore along the east coast of Swona Island.
“However, with the chief engineer working independently behind him at the bridge engine console and without a lookout to observe or assist him, the master was effectively navigating the vessel alone. The cause of the master’s temporary loss of awareness, which is consistent with his discussion captured on the VDR [voyage data recorder] after the accident, was almost certainly that he fell asleep.
“The master’s routine hours of work and rest complied with the Merchant Shipping (Hours of Work) Regulations 2002. His routine allowed him to rest while the vessel was in port and provided him with an uninterrupted 11 to 13-hour off-duty period overnight. However, these regulations only applied when the master was on board the vessel and did not prevent the master joining Alfred, from leave, after only five hours of sleep at home.
“Just over 10 hours later, on the passage north from Gills Bay and having only had an opportunity to leave the bridge and relax while in harbour, it is highly likely that he was experiencing some fatigue. This fatigue, occurring during the post-lunch danger period (mid-afternoon circadian low), combined with sitting on a bright, warm, sunlit bridge completing a familiar low workload task, made the master susceptible to experiencing a short sleep of approximately 70 seconds duration. This could explain his late detection of the rapidly approaching shoreline and why there was insufficient time for him to take action to prevent the vessel grounding.”
The report noted that the master was not supported by a seaman on the bridge. “Consequently, the master’s loss of awareness and the developing dangerous situation went unnoticed.”
The report also stated: “On the day of the accident Alfred’s master was navigating the ferry very close to the islands of Stroma and Swona by eye; a route that he had followed many times before.
“It is unclear why the master was following these inshore routes. However, given that this deviation from the passage plan was not the most direct route to St Margaret’s Hope, it is probable that he wanted to show the passengers the scenery. Further, having completed over 20,000 crossings of the Pentland Firth without serious incident, it is likely that he had become desensitised to the associated risks of passing so close to navigational danger; a significant area of nonconformity that had not been identified during the vessel’s many surveys, audits and inspections.”
