What happened
The Fiordland Navigator was a passenger vessel that operated from Deep Cove in Doubtful Sound, New Zealand. It offered an overnight tourism voyage in Doubtful Sound, with the route depending on the conditions at the time. On 24 January 2024, as the vessel was being turned to exit an arm of Doubtful Sound (Crooked Arm), it is virtually certain that the master fell asleep and the vessel ran aground.
There were nine crew and 57 passengers on board. The grounding resulted in a number of minor injuries to the crew and passengers and moderate damage to the vessel. The emergency response was effective, with the passengers evacuated to Deep Cove then on to Te Anau that evening. The vessel returned to Deep Cove that night.
Why it happened
The master was very likely subject to fatigue impairment due to inadequate rest periods. The Operator’s Fatigue Management Guidelines did not assure adequate rest periods for the crew, and those rest periods were not implemented effectively. The master was also taking medication that had the potential effects of drowsiness. While it may have contributed to the master’s impairment, the Transport Accident Investigation Commission was unable to determine if it had.
The master held a current Maritime New Zealand Certificate of Medical Fitness that should have identified the risks of medication side effects, but the master had begun taking the medication after the certificate was issued. There were no prompts or requirements for Certificate of Medical Fitness holders to ensure they met the prescribed medical standards throughout the two-year validity of the certificate.
The Fiordland Navigator was operated by a sole-charge master. However, the hazards presented by a sole-charge master, such as incapacitation, had not been explicitly identified or mitigated in the vessel’s risk register. As a result, there was inadequate mitigation in place when the master became incapacitated.
The implementation of elements of the vessel’s safety management system was ineffective because the manager responsible was burdened with a workload significantly beyond that which one person could have reasonably handled. This hindered the fatigue management of the masters and crew and diminished the likelihood of effective risk identification and mitigation-control implementation.
What we can learn
A person’s medical fitness for duty should be considered an ongoing state rather than a state judged through a one-time certificate for approval.
When a person is operating in a safety-critical role, any new medications they take should be considered for potential performance-impairing effects.
Master incapacitation is a significant risk on sole-charge vessels.
Adequate resources are necessary to ensure the effective implementation of safety management systems.
Who may benefit
The people and entities that may benefit from the findings and recommendations in this report include: people with safety-critical roles who could be affected by fatigue or medication; sole-charge operators; those associated with Certificates of Medical Fitness; those who operate safety management systems; auditors and regulators; maritime schools; and maritime industry bodies.
