MO-2024-201 Passenger vessel, Fiordland Navigator, Grounding, Doubtful Sound, 24 January 2024

What happened

1. 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.
2. 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

1. 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.
2. 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.
3. The Fiordland Navigator was operated by a sole-charge master. However, the hazards presented by a sole-charge master, such as incpacitation, 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.
4. 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

1. 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.
2. When a person is operating in a safety-critical role, any new medications they take should be considered for potential performance-impairing effects.
3. Master incapacitation is a significant risk on sole-charge vessels.
4. Adequate resources are necessary to ensure the effective implementation of safety management systems.

Who may benefit

1. 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.

Narrative

1. At about 0700 on Thursday 18 January 2024, the master and eight crew of the Fiordland Navigator (a cruise vessel offering overnight tourism voyages) met at Manapouri to transit by road to Deep Cove in Doubtful Sound. Once there, they began preparing for their shift.
2. At about 1000 the Fiordland Navigator returned at Deep Cove from its previous voyage and its crew began disembarking the passengers. The outgoing and incoming masters conducted a handover that took about 10 minutes.
3. The crew undertook hospitality duties (such as providing clean laundry), loaded stores and had lunch. The Fiordland Navigator was then taken off the berth to free it for the Milford Wanderer, and subsequently returned to the berth. The crew embarked the passengers on board the Fiordland Navigator at about 1430 and the vessel departed for the first voyage of the swing.
4. The master directed the Fiordland Navigator to an anchorage, where the passengers engaged in water activities such as kayaking. The vessel was secured at a fixed mooring so that the master could leave the wheelhouse (the skipper usually remained in the wheelhouse when the vessel was anchored) to deliver training to three crew members.
5. At about 1830 a dinner service was delivered for the crew and passengers, and at about 2000 the master had their dinner. They retired to bed at about 2200.
6. The master woke at about 0545 the next day and began preparing the vessel for service at around 0600. The vessel then departed the anchorage and returned at Deep Cove at 1000 to disembark the passengers. The crew then began preparing the vessel for the next voyage, with passengers embarking at around 1430.
7. The crew undertook similar routines in the next five days, Friday through to Tuesday.
8. On Wednesday 24 January at 0545, the master awoke and began preparing the vessel for service.
9. At about 0630 the master started the vessel’s engines, weighed anchor and returned to Deep Cove to disembark the passengers at about 1000.
10. As a result of a disagreement between the team leader and another crew member the previous evening, the team leader disembarked the vessel and was replaced by the onshore-based overnight manager.
11. The vessel was taken off the wharf at 1020 to allow access for the Milford Wanderer and was back on the wharf at 1040. The vessel was taken off again at 1220 and returned at 1245.
12. The crew began embarking passengers at 1430. Once this was complete, the vessel departed for Crooked Arm at about 1445. The Fiordland Navigator anchored for water activities (various water activities, such as kayaking, were available to the passengers) between 1550 and 1620, then was moved and anchored again from 1640 to 1740 (see Figures 3 and 4).
13. The master commenced the transit out of Crooked Arm, and at approximately 1804 began the turn to port.
14. It is virtually certain that the master fell asleep during the turn to port and the vessel continued turning. At approximately 1807 the Fiordland Navigator ran aground while travelling at about 10.8 knots (20 kilometres per hour).
15. The master woke when the vessel came to a sudden stop. They were still sitting in the master’s chair. They immediately assessed the situation and began the emergency response, mustering the passengers using the public address system and calling the onshore manager to alert them to the accident.
16. The crew reported to their muster stations. Two crew were assigned to damage assessment and one to the operating bilge pumps. The remainder had roles mostly around mustering passengers and assessing them for injuries.
17. The vessel damage included a small hole below the waterline, but the rate of water ingress was not a material threat to the safety of the vessel. The use of a small bilge pump was enough to clear incoming water.
18. The Milford Wanderer, a sister vessel, was nearby, so a crew member there used the tender to travel to the Fiordland Navigator and assist in the response.
19. At about 1920 the tide had come in enough to lift the vessel off the rocks and enable the Fiordland Navigator to get underway.
20. Two nearby fishing vessels came alongside and rafted-up7 to the Fiordland Navigator. The passengers were transferred to the fishing vessels and departed for Deep Cove at about 2000.
21. Meanwhile, in Te Anau, RealNZ (a company that operated tours, cruises and other activities in the area) had assembled two response teams to go to Doubtful Sound by helicopter. One team would assist the passengers when they reached Deep Cove, and the other would travel to the vessel to assist on board.
22. On their arrival at Deep Cove, the passengers were assessed by a doctor from the response team before departing for Te Anau by bus at around 2115.
23. The response team then travelled to the vessel, arriving on board at around 2200. The vessel began making way (propelling itself to move through the water) for Deep Cove at about 2230 and was alongside by 2357.
24. Repairs and requisite surveys were conducted, and the vessel returned to service in the following week.

Vessel information

1. The Fiordland Navigator tourism operation involved taking passengers on overnight trips to Doubtful Sound. Doubtful Sound is a popular destination for tourists and the second-largest fiord in Fiordland National Park. It is isolated, with no direct road access, and home to abundant wildlife.
2. The Fiordland Navigator was certified to carry 150 passengers within enclosed water limits (the specific areas identified in Part 1 of Appendix 1 of Maritime Rule Part 20 and all New Zealand inland waters) and 85 passengers within inshore limits (the limits set out in Part 2 of Appendix 1 of Maritime Rule Part 20 and in relation to a ship, any defined section of the coastal limits not beyond the limit of the territorial sea of New Zealand (which has been assigned to that ship as an inshore limit by a surveyor under rule 20.20(1)), subject to rule 20.20(4)).
3. The vessel was a three-masted schooner constructed in steel in Invercargill in 2001. The vessel particulars were:

1. The vessel was operating within enclosed waters and had 57 passengers on board at the time of the grounding.

Personnel information

1. The Fiordland Navigator’s Minimum Safe Crewing Document (MSCD) required a crew complement of four: one person with a Skipper Restricted Limit (SRL) <3000 gross tonnage qualification and three other seafarers.
2. The master held a Commercial Launch Master Certificate of Competency issued in 1997, which had the same privileges as the SRL and also >3000 gross tonnage. They had joined RealNZ in 1998 and been master of the Fiordland Navigator for the previous 15 years.
3. The Fiordland Navigator’s on-board hospitality service required nine crew, including the master. They operated on a week-on/week-off swing, with change-over days on Thursdays. The crew were as follows:

1. The eight crew members were at various stages of training in the RealNZ internal training system. The system had three stages, with stage 3 being the highest level. Stage 3 was at a lower level of training than the historical internal RealNZ position of ‘Masters Assistant’, which had become obsolete during the COVID-19 pandemic. ‘Masters Assistant’ had been a New Zealand Qualifications Authority-approved qualification, and part of the role had been to support the master as needed.
2. While not having a formal maritime qualification recognised by Maritime New Zealand (Maritime NZ), a person qualified at stage three could stand watch in the wheelhouse should the master need to leave for short periods, such as to respond to radio calls.

Medical information

1. The master’s SRL qualification required them to have a Maritime NZ Certificate of Medical Fitness – National or Ring-Fenced Seafarers (Certificate of Medical Fitness) (issued by a doctor (see Appendix 1)). The master held the qualification with no special restrictions. At the time of the grounding, they were taking medication that had the potential side effect of drowsiness.
2. The Certificate of Medical Fitness template is shown in Appendix 1.
3. Maritime Rules Part 34: Medical Standards sets the standards of medical fitness for seafarers.

4. Part 34.23: Examination of seafarers for certificate of medical fitness states that:

   A medical practitioner carrying out a medical examination of a seafarer… must… comply with the instructions and take into account any guidance for the conduct of medical examinations outlined in Part 3 of the International Labor Organization and International Maritime Organization guidelines on the medical examination of seafarers.

5. Maritime NZ provided two guidance documents pertinent to the Certificate of Medical Fitness: Guidance for medical fitness – National or Ring-fenced seafarers (Guidance for Medical Fitness) and the GP [General Practice] Summary Guide for Medical Fitness – National or Ring-fenced seafarers.
6. The Guidance for Medical Fitness stated that the purpose of the Certificate of Medical Fitness was to certify seafarers’ fitness for two years

7. It also prompted a consideration of medications and potential side effects:

   11. If prescribing medications for a seafarer or reviewing the medications being taken:

• some medications can have side effects, affecting the performance of duties

• effectiveness/use of oral medication at sea may be prevented by nausea and vomiting.

  12. International guidance on medications that can impair routine and emergency duties include those that:

• affect central nervous system functions (e.g. sleeping tablets, antipsychotics, some analgesics, some anti-anxiety and anti-depression treatments and some antihistamines)
• increase the likelihood of sudden incapacitation (e.g. insulin, some of the older anti-hypertensives and medications predisposing to seizures)
• impair vision (e.g. hyoscine and atropine).

1. The GP Summary Guide included a prompt to:

   Discuss / cover medical history – Past and current illnesses, diseases, surgery, conditions, injuries and medication.

Organisational information

1. The Fiordland Navigator was operated by RealNZ. RealNZ was the trading name for Real Journeys Ltd. RealNZ’s vessel operations spanned tourism, passenger, general cargo and work boat activities. RealNZ also operated land transport, including buses.
2. The RealNZ fleet comprised 34 vessels (one being the Fiordland Navigator) with overall lengths of about 6–50 metres, and operational bases in seven locations in the South Island. The bases were divided into three areas: Queenstown; Te Anau/Manapouri/Milford/Doubtful Sound; and Bluff/Stewart Island. The fleet was operated by up to 50 Launch Masters, of which one was the master of the Fiordland Navigator.
3. There had been a management restructure in 2023. Prior to the restructure, all Launch Masters had reported to the Chief Launch Master, who had reported to the Head of Maritime Operations.
4. Under the restructure, the Chief Launch Master role was disestablished and divided into two roles: a Senior Launch Master (SLM) for Queenstown operations and an SLM for Fiordland/Rakiura operations. The SLMs reported to their respective General Managers of Experience (GMs Experience) (the SLM Fiordland reported to the General Manager of Experience Fiordland/Rakiura and the SLM Queenstown reported to the General Manager of Experience Queenstown) rather than the Head of Maritime Operations. There remained a ‘dotted report line’ to the Head of Maritime Operations for ‘technical/compliance leadership’.

Previous occurrences

1. The Transport Accident Investigation Commission (Commission) has previously made recommendations on safety issues similar to those described in this report. The previous findings and recommendations are summarised below.

Fatigue management

2. The Commission recommended that KiwiRail implement arrangements to detect and manage stress and fatigue, including proper rest breaks and nutrition (RO-2011-102, recommendation 014/13).
3. The Commission recommended that KiwiRail review its Fitness for Work Policy to better manage workloads and mitigate fatigue risks for safety-critical personnel (RO-2014-105, recommendation 017/17).
4. The Commission recommended that KiwiRail develop and implement a comprehensive fatigue risk management system (RO-2017-101, recommendation 019/18)
5. The Commission recommended that Oceanic Fishing Ltd establish appropriate fatigue-management policies and procedures for its fleet (MO-2021-203, recommendation 003/22).

Medical fitness

3. On 22 August 2023 (MO-2022-202, recommendation 027/23) the Commission recommended that Lyttelton Port Company Ltd review the medical screening of stevedores to ensure it provided adequate assurances of medical fitness for their duties and responsibilities.
4. In 2017 (Addendum to Final Report AO-2015-002, recommendation 022/17) the Commission found that there was the potential for applicants for aviation medical certificates to circumvent the process and inaccurately represent their health by misreporting their treatments, failing to disclose medications and using multiple GPs and other health professionals. The Commission noted that this risk was shared by other transport modes that required people to hold medical certificates or make declarations on their health status. The development of a national health database would provide one means to address this risk. On 28 June 2017 the Commission recommended to the Chief Executive of the Ministry of Health that it consider adding the following functions to the national electronic health record database that was then under development:

• that a person’s occupation be added to the record to allow monitoring of individuals who hold transport-related documents that require periodic medical checks, and who have potentially adverse health conditions or medications, so that the appropriate authority can be alerted to possible public safety risks
• a mechanism to draw the attention of all health practitioners to their obligation to notify the appropriate transport authority when a person or patient has a health condition or need for medication that could pose a threat to public safety in that individual’s occupation.

On 3 July 2017 the Chief Medical Officer for the Ministry of Health replied:

The National Electronic Health Record Business Case project is a significant project that is working though a Treasury Better Business Case (BBC) process. This process is for agencies that have significant proposals that will have a whole of life cost of more than $25 million.

The BBC process has a number of stages and at this point we are close to completing stage 2 of 4. At the completion of stage 4 we expect that we will begin to implement the solution for the National Electronic Health Record, timing for the duration of the implementation phase is yet to be determined. With our current timeline, we expect this to begin no earlier than late 2018 pending approval from Cabinet and successfully delivering the business case process and large scale procurements required.

With these timings in mind, we recognise that there is a requirement to hold the occupation for an individual and to be able to undertake reporting and processes related to the occupation should potentially adverse health and/or medications be identified. At this stage we cannot commit that the functionality that has been suggested will be implemented and will not be in a position to do so until the Business Case process is completed. However, while we cannot yet confirm the details of this type of functionality, we can and will take this into account during our deliberations and include in our business case documentation the advantages of having this type of functionality tied into the Electronic Health Record once established.

1. In 2015 (RO-2012-104, recommendation 011/15) the Commission recommended that KiwiRail introduce a system in which KiwiRail medical professionals would be automatically granted access to employee medical records held by private medical practitioners as necessary, to ensure that employees who performed safety-critical roles were not impaired by prescription or over-the-counter medications.

Sole-charge master

1. In 2012 (MO-2010-202, recommendation 019/12) the Commission recommended that Maritime NZ require New Zealand-registered coastal vessels conducting one-man bridge operations to have bridge-watch navigational and alarm systems to mitigate the known risks of sole watchkeepers falling asleep or becoming distracted from monitoring the progress of their vessels.
2. In 2024 (MO-2023-202) the Commission found that the Maritime Transport Operator Plan (MTOP) of a passenger ferry had not identified and mitigated the risks of a sole-charge master being incapacitated, and instead had relied on one person (the master) to manage the safety of the passengers in an emergency.

Introduction

1. The following section analyses the circumstances surrounding the event to identify those factors that increased the likelihood of the event occurring or increased the severity of its outcome. It also examines any safety issues that have the potential to adversely affect future operations.

What happened

2. The master of the Fiordland Navigator was on the sixth day of a seven-day swing. The evidence indicates that it is virtually certain the master fell asleep while navigating the vessel, and it subsequently ran aground. The master was very likely suffering from workload-induced fatigue that had not been recognised or mitigated by the operator’s safety management system. This may have been compounded by a potential drowsiness side effect of a prescribed medication they were taking, but the Commission was unable to make a determination on this.
3. With the sole-charge master asleep, there was no defence in place to stop the vessel continuing its track and running aground. The crew’s training and performance were effective in delivering an organised response and recovery without further issue.
4. The causes and circumstances of this accident are discussed in the following sections.

Fatigue management

Safety issue 1: The operator’s fatigue-management practices were insufficient to mitigate the risk of fatigue-related impairment. As a result, it was very likely that the crew’s ability to perform their duties safely was significantly compromised.

1. The Maritime Operator Safety System (MOSS) is a framework established by Maritime NZ to enhance safety in maritime transport operations. It requires commercial vessel operators to develop and maintain comprehensive safety systems that cover not just their vessels but their entire maritime operations. One component of MOSS is the MTOP.
2. Under its MTOP, RealNZ had Fatigue Management Guidelines (FMGs) that applied to all RealNZ operations, including land transport.
3. Under the FMG, land transport operations had prescribed hours of rest that were recorded and regulated (hours of rest for land transport operators were regulated by the NZ Transport Agency) whereas seafarers had recommended hours of rest that were not recorded or regulated.
4. The FMG noted that the International Convention on Standards of Training, Certification and Watchkeeping for Seafarers (Section A-VIII/1 of the Code addresses the fatigue management of seafarers) was applicable. In particular, the FMG required that rosters have four general limitations:

• A minimum of 10 hours’ rest in any 24-hour period
• The rest hours to be divided into no more than two rest periods, and one rest period must be at least six hours long.
• No working period to be longer than 14 hours.
• A minimum of 77 hours’ rest in any seven-day period.

1. Specific to the Fiordland Navigator, the workday was predicated on 14 hours of work, with an expected rest period between tourist trips while the vessel was alongside. Additionally, qualified and experienced staff were expected to be available to stand watch to allow the master short breaks.
2. The master described their workday as beginning at around 0600 and finishing at around 2200, being a 16-hour working period. This allowed them about eight hours of overnight rest. However, the quality of the sleep was difficult to determine, because sole-charge masters bear full responsibility for their vessels and their sleep may be broken by many things, including changes in weather and vessel movements.
3. The master’s 16-hour workday should have been reduced to 14 hours by a two-hour rest period while the vessel was alongside. However, while the vessel was alongside the master conducted other duties that included routinely taking the vessel on and off the berth to accommodate the movement of other vessels. In addition, on the day of the accident the master was preparing the vessel for handover to the next master the following day.
4. Short rest periods were available to the master during the trips and when the vessel was moored, but some of these were used by the master to train the crew. As a result, the planned daily rest period between sailings was often reduced, and on the day of the accident it was negligible.
5. It was unlikely that the master fully utilised the intended daily five-hour rest periods between sailings in the seven days in which they were on board the vessel.
6. The cumulative effect of reduced rest and a seven-day working period meant it was very likely that the master was impaired by fatigue.

7. The FMG stated:

   “… it is the direct responsibility of all managers to monitor the level of fatigue and general wellbeing in their workforce for signs and symptoms that fatigue and related issues are reaching a hazardous stage.”

8. The FMG also stated that all managers were responsible both for ensuring that rosters did not lead to individuals suffering hazardous fatigue, and for monitoring fatigue within the workforce. The wording of the FMG created uncertainty in relation to which of the three managers available to the Fiordland Navigator (the GM Experience, the overnight manager and the SLM), or all three, were responsible for managing fatigue. The Commission’s interviews of the managers also demonstrated uncertainty about who was responsible.

9. The MTOP mentioned the responsibility of only one managerial role – the SLM’s (there were two SLMs at RealNZ) – being:

   “responsible for ensuring the day to day practical function of the MTOP through engagement with vessel crew”.

10. In addition to their role in fatigue management, the SLM carried an overwhelming workload that made it very difficult for them to ensure all practical functions of the MTOP were undertaken appropriately. This issue is discussed further under safety issue 4.
11. The FMG required all staff to take responsibility for presenting to work in a fit state, and to “look out for one another”. There was evidence that operational staff did consider fatigue management: for example, masters regularly discussed weather conditions and their overnight rest periods with the GM Experience.
12. The FMG also indicated that all staff would receive formal training in fatigue management where practical. Some masters and managers had undergone this training, although not the master of the Fiordland Navigator.
13. The FMG referred to a self-assessment form for fatigue and wellbeing that all staff could use. However, the Commission found no evidence that this form was utilised by staff as guidance or completed and submitted.
14. No system had been established to record or monitor actual hours of work and rest, as opposed to scheduled hours of work and rest. Consequently, there was no consistent mechanism for assessing the effectiveness of RealNZ’s fatigue-management policy.
15. Although there were guidelines in place to manage fatigue, their implementation was inadequate and there was no effective mechanism for identifying and respond to fatigue.

Certificate of Medical Fitness

Safety issue 2: The standards of the Maritime NZ Certificate of Medical Fitness for seafarers are not fully captured in the certificate itself, and therefore certificate holders may not appreciate their ongoing responsibilities should their medical conditions change. As a result, pertinent health conditions can go unknown to the operator and the seafarer and compromise the seafarer’s ability to perform their duties safely.

1. The Commission was unable to determine if the medication the master was taking, which had the potential to cause drowsiness, contributed to their falling asleep.
2. The master’s medical fitness for duty was assured by their Certificate of Medical Fitness, issued by a medical examiner in accordance with Maritime Rules Part 34: Medical Standards. The standards required the medical examiner to consider vision, hearing, physical capability, medication and medical conditions. Pertinent to this accident, the medical examiner was required to consider potential impairments due to medication taken by certificate holders prior to issuing Certificates of Medical Fitness.
3. Maritime Rule Part 34 – Medical Standards, the GP Summary Guide for Medical Fitness, and the Guidance for Medical Fitness (outlined in section 2 of this report) indicate that the Certificate is meant to ensure a broader scope of medical fitness than that stated in the template. The template requires evaluations to be conducted in accordance with Part 34, but has only two prompts:

• Does the seafarer meet vision standards?
• Does the seafarer have satisfactory hearing?

1. The template includes a section for the medical examiner to record restrictions, but does not prompt the inclusion of any other health conditions the medical examiner should consider (for example, medications) or refer to the guidance documents provided by Maritime NZ.
2. The master held a Certificate of Medical Fitness that had been issued before they began taking the medication that had the potential side effect of drowsiness. So, while current, the Certificate of Medical Fitness potentially no longer met the standards specified in Part 34 of the Maritime Rules and the master was at an increased risk of operating the vessel while cognitively impaired.
3. Both the operator and the certificate holder have important parts to play in managing employee fitness. However, the master said they were not aware of the potential side effects of the medication, and it was unclear what information had been provided by the General Practitioner (GP) who prescribed it. The GP who had issued the certificate differed from the GP who had prescribed the medication.
4. Further, the Certificate of Medical Fitness template did not require a declaration of any health conditions other than those related to eyesight and hearing, nor did it require an assessment of health conditions that had changed since it had been issued. This meant there was no prompt for the master to consider the effects of medication on their medical fitness, either at the time the Certificate was being issued or during the two-year period in which it was valid.
5. RealNZ had an internal medical assessment process (see Form A in Appendix 2) that was conducted in addition to, and was significantly more comprehensive than, the Maritime NZ Certificate of Medical Fitness. However, the internal medical assessment process was discontinued when RealNZ’s operations were restricted during the COVID-19 pandemic. This meant that, at the time of the accident, there was no prompt for the master to declare to the company that the medication they had been prescribed might cause drowsiness.
6. The Commission has made a recommendation to Maritime NZ on this safety issue.

Risks of sole-charge master

Safety issue 3: The vessel grounded because the risks associated with a sole-charge master were not adequately identified or mitigated by the vessel’s safety management system.

1. The Fiordland Navigator’s MSCD, which applied on the day of the accident, required a crew complement of one SRL and three seafarers.
2. The Maritime Rules define a seafarer as any person who is paid to work on board a vessel. There is no minimum qualification for a person to be a seafarer, so the only person on board who needed to be qualified to operate the vessel, and who was solely responsible for navigational safety, was the master.
3. The MSCD did not prescribe the crew’s deployed on board. That was dependent on the operator’s safety management system and risk controls.

4. A significant risk for a vessel with a sole-charge master is their incapacitation. Incapacitation can result from various events, including the master falling asleep. The only mention of the risks of a sole-charge master in RealNZ’s safety management system is in the FMG, with risks for the Fiordland Navigator including:

   “Master excess fatigue due to lack of mate/relief”

    

5. The FMG’s mitigation for that hazard was to provide daytime relief when more than three ‘day trips’ were scheduled. However, the Fiordland Navigator day trips had been discontinued to enable more rest for the master. The mitigation also referenced qualified and experienced crew, including the master’s assistant, which was no longer an operational role.
6. Most of RealNZ’s vessels were under sole-charge masters. However, the hazards associated with sole-charge masters were not explicitly identified in the risk register. Consequently, there were no specific risk mitigations in place, although some measures that applied to other risks also applied in some ways to master incapacitation. For example, crew had training in how to steer the vessel and put propulsion system controls to neutral to allow the master time for bathroom breaks and similar short departures from the wheelhouse.
7. Had a risk assessment been carried out and identified sole-charge masters as a hazard, it is very likely that more robust mitigation measures would have been in place on the Fiordland Navigator.
8. After the grounding, RealNZ introduced a requirement for a second person in the wheelhouse during the navigation of the vessel, so that there would be immediate mitigation should the master become incapacitated.
9. The Commission welcomes the safety action taken by RealNZ.

Implementation of MTOP

Safety issue 4: The role within RealNZ with responsibility for the day-to-day implementation of the MTOP was not sufficiently resourced. This increased the likelihood of risk mitigations not being applied to full effect.

1. Two managers were responsible for the MTOP in the Fiordland/Rakiura area (the deliverables for the roles are described in Appendix 3):

• The Head of Maritime Operations’ role was directed towards compliance.
• The SLM was responsible for the day-to-day implementation of the MTOP for all the RealNZ vessels.

1. The SLM role was one person, and their responsibilities included (but were not limited to):

   Ensure the day-to-day practical elements of the MTOP are being adhered to through regular engagement with the vessel Launchmasters and crew. This includes but not limited to ensuring safe operating practices are always followed, planned maintenance checks, voyage/trip planning is conducted, and management of all hazards is maintained and recorded.

    

2. All RealNZ masters in the Fiordland/Rakiura area reported to the SLM. This meant the SLM had about 30 direct reports in addition to their MTOP responsibilities. However, they were not responsible for all aspects of the other masters’ roles.
3. Further, the SLM was rostered on as an operational master for about 50% of their time.
4. The SLM’s primary reporting line changed in 2023 as a result of a restructure within RealNZ. Under the new structure, the SLM reported to the GM Experience rather than the Head of Maritime Operations. This put an additional load on the SLM, as the GM Experience was not embedded in the daily complexities of maritime operations and had non-maritime responsibilities and deliverables alongside their responsibilities under the MTOP.
5. An internal audit of the Fiordland Navigator found that the annual review and updates of the safety manual and the risk register had not been conducted in 2023, and it was unclear when they had last been conducted.
6. The Commission found it was unreasonable to expect the SLM to meet their responsibilities for the day-to-day implementation of the MTOP given the number of deliverables for that role.
7. The GM Experience acknowledged during interview that the SLM role was too big for one person and, following the accident, additional resources were provided. The Commission welcomes the safety action taken.

1. The crew’s training and performance were effective during the emergency response.
2. It is virtually certain the master fell asleep while navigating the vessel, and it subsequently ran aground.
3. The master was very likely suffering from work-load-induced fatigue, which had not been recognised or mitigated by the operator’s safety management system.
4. Management’s oversight of crew fatigue was insufficient to ensure compliance with the Fatigue Management Guidelines.
5. The actual rest hours of the master were very likely less than those prescribed in RealNZ’s Fatigue Management Guidelines.
6. RealNZ did not have a system for recording or monitoring actual hours of work and rest, as opposed to scheduled hours of work and rest. Consequently, there was no consistent mechanism to identify breaches of RealNZ’s fatigue-management policy.
7. The Commission was unable to determine if the medication the master was taking, which had the potential to cause drowsiness, contributed to the master’s falling asleep.
8. The risks associated with sole-charge masters had not been explicitly identified by RealNZ. Had a risk assessment been carried out and identified sole-charge masters as a hazard, it is very likely that more robust mitigation measures would have been in place on the Fiordland Navigator.
9. A Certificate of Medical Fitness does not adequately assure that the holder is medically fit for duty during the two-year period of its validity.
10. The Senior Launch Master role was responsible for the day-to-day implementation of the Maritime Transport Operator Plan but had a workload that made it difficult for them to carry out this function.

General

1. Safety issues are an output of the Commission’s analyses. They may not always relate to factors directly contributing to the accident or incident. They typically describe a system problem that has the potential to adversely affect future transport safety.
2. Safety issues may be addressed by safety actions taken by a participant, otherwise the Commission may issue a recommendation to address the issue.

Safety issue 1: The operator’s fatigue-management practices were insufficient to mitigate the risk of fatigue-related impairment. As a result, it was very likely that the crew’s ability to perform their duties safely was significantly compromised.

1. Following the incident, RealNZ informed the Commission of the following:

   The Fatigue management policy has been reviewed and now includes a specific maritime guideline appendix. This guideline assesses fatigue risks for each specific area and details controls and options to minimise risk of fatigue.

   The updated fatigue policy and guidelines have been rolled out through:

• Launch Master training workshops in person
• Updated documentation on board all vessels
• In-person meetings for shore based operational staff
• Regional Launch Master forums
• skipper forums
• a requirement for Launch Masters on an ongoing basis to share and take staff through this.

• Future plans for “quick guides” to assist Masters with crew training on the key points.

  Implemented an improved system to better capture the hours worked and rest breaks taken for the Launch Masters and crew on the vessels. This is to ensure that the new aspects will allow [Real Journeys] to better understand whether the Fatigue Management Policy is being complied with by staff and that the controls are effective.

  Real Journeys has implemented a programme of work to install Auto Pilots on additional specific vessels. The benefits of this include reducing the Launch Masters workload and enable movement around the vessel wheelhouse rather than remaining seated when at the helm.

1. In the Commission’s view, this safety action has addressed the safety issue. Therefore, the Commission has not made a recommendation.

Safety issue 2: The standards of the Maritime NZ Certificate of Medical Fitness for seafarers are not fully captured in the certificate itself, and therefore certificate holders may not appreciate their ongoing responsibilities should their medical conditions change. As a result pertinent health conditions can go unknown to the operator and the seafarer and compromise the seafarer’s ability to perform their duties safely.

1. The Commission has made a recommendation in Section 6 to address this issue.
2. RealNZ is in the process of reinstating its internal medical assurance for critical roles. The Commission welcomes the safety action taken by RealNZ.

Safety issue 3: The vessel grounded because the risks associated with a sole-charge master were not adequately identified or mitigated by the vessel’s safety management system.

1. Safety actions taken by RealNZ following the incident included adding a second person to the wheelhouse during the navigation of a vessel to support the master, and:

   The role of a vessel Master’s Assistant was re-instated in 2024. A new competency framework was designed and implemented.

   These roles are in place now with ongoing training and development. This role supports the vessel Launch Master in a navigational and maritime context.

   Post the 2024 season, we are further reviewing the Master’s assistant training to assess the effectiveness of the role, and improvements for 2025.

   Crew training continues to include Master Incapacitation training for the Real Journeys Stages 1-3 training levels.

   Refer to the above-mentioned Auto Pilot programme.

2. In the Commission’s view, this safety action has addressed the safety issue. Therefore, the Commission has not made a recommendation.

Safety issue 4: The role within RealNZ with responsibility for the day-to-day implementation of the MTOP was not sufficiently resourced. This increased the likelihood of risk mitigations not being applied to full effect.

1. The safety actions taken by RealNZ following the incident included reducing the hours in which the SLM was rostered on as master, and:

   Real Journeys has developed and implemented a new role of Maritime Resource Planner. The role functions include:

• planning forecasted maritime resource
• monitoring maritime resource for competency, compliance and fatigue management of Launch Masters and crew
• ensuring adequate maritime resourcing
• providing administrative support to Senior Launch Masters

• supporting the Maritime Safety function.

  Real Journeys has amended the area of responsibility for the Fiordland/Rakiura Senior Launch Master. This role now has fewer direct reports. Further review of this role and the structure is currently under review.

  Real Journeys has also implemented a more comprehensive personalised leadership training programme focused on the needs of the individual. This is developed and monitored through the RealNZ Personal Development Programme.

1. In the Commission’s view, this safety action has addressed the safety issue. Therefore, the Commission has not made a recommendation.

General

1. The Commission issues recommendations to address safety issues found in its investigations. Recommendations may be addressed to organisations or people and can relate to safety issues found within an organisation or within the wider transport system that have the potential to contribute to future transport accidents and incidents.
2. In the interests of transport safety, it is important that recommendations are implemented without delay to help prevent similar accidents or incidents occurring in the future.

New recommendation

1. On 27 February 2025, the Commission recommended that Maritime New Zealand implement measures to raise awareness of the standards for the Certificate of Medical Fitness for seafarers and ensure that certificate holders understand their responsibilities to maintain certificate validity and report any impacting changes. [028/25]

2. On 7 April 2025, Maritime New Zealand replied:

   Maritime NZ will consider this recommendation.

   Maritime NZ recognises the importance of seafarers being medically fit. We have previously sought to, and continue to ensure that seafarers and their operator employers are aware of the requirement to maintain medical certification under Maritime Rules Part 34. This is communicated through a number of stakeholder channels including publications such as Seachange (see article published in the July 2024 - https://mailchi.mp/mnz/seachange-issue-111-july-2691019).

   We also monitor the validity of medical certificates through our audit activity, including checking the expiration dates of both the skipper and crew during our Maritime Operator Safety System audits.

   Our work underway to develop an online interface that enables greater, and more efficient, digital interaction between the sector and Maritime NZ will allow us to more clearly communicate requirements (including medical), and seafarers will be enabled to more easily report changes to their medical status.

1. Medical fitness for duty should be considered an ongoing condition rather than a single moment in time when issuing a medical certificate.
2. Any new medications should be considered for potential performance-impairing effects.
3. Master incapacitation is a significant risk on sole-charge vessels.
4. Management needs to be adequately resourced to ensure the effective implementation of safety management systems.

1. On 24 January 2024, Maritime New Zealand notified the Commission of the occurrence and where the Fiordland Navigator had run aground. The Commission opened an inquiry into that incident under section 13(1) of the Transport Accident Investigation Commission Act 1990 and appointed an investigator in charge.
2. On the same day the Commission issued a protection order under section 12 of the Transport Accident Investigation Commission Act 1990, to preserve the evidence on board the Fiordland Navigator.
3. Between 25 and 29 January 2024, two investigators travelled to Te Anau and Queenstown to gather information. Another investigator travelled to Te Anau between 26 and 28 January to gather further information.
4. On 23 October 2024 the Commission approved a draft report for circulation to seven interested parties for their comment.
5. Six interested parties provided detailed submissions, and one interested party replied that they had no comment. Any changes as a result of the submissions have been included in the final report.
6. On 27 February 2025 the Commission approved the final report for publication.

*Note that the Wayfare Group was formed in 2018 but was relaunched as RealNZ on 1 October 2021.