NTSB says Cathlamet ferry crash was caused by pilot fatigue and complacency
Thu, 10/12/2023
The National Transportation Safety Board has issued its report on the July 28, 2022 crash of the ferry Cathlamet the Fauntleroy Ferry Dock.
On July 28, 2022, about 0814 local time (8:14 AM) , the passenger and car ferry Cathlamet had crossed Puget Sound and was approaching the Fauntleroy Ferry Terminal in Fauntleroy, Washington, with 94 persons on board when the vessel struck a ferry terminal dolphin.1 One minor injury was reported. The damage to the vessel was estimated at $10 million, and the dolphin damage estimate was $300,000.
SEE THE FULL REPORT HERE
From the report:
"On July 28, 2022, the Cathlamet was operating on the North Vashon Triangle Route, between Vashon Island, Southworth, and Fauntleroy, Washington.2 While the vessel was transporting passengers and vehicles, two separate deck watch sections rotated between duty and rest periods. Each deck watch section consisted of a master, chief mate, four able seamen (with one designated as the quartermaster) and three ordinary seamen. The engineering department only had one duty section on board while the vessel was operating.
About 0345, a new deck watch section reported on board at Vashon Island and relieved the off-going deck watch section, which departed the ferry. The other deck watch section remained on board the vessel resting. The newly arrived chief mate and quartermaster assumed navigation of the vessel. They navigated the vessel between stops on the ferry route until 0720, when the master, who had been walking around the vessel or in the crewmember break room since reporting on board (about 0345), relieved the chief mate while the vessel was docked at Fauntleroy. Shortly thereafter, the Cathlamet departed Fauntleroy and then arrived at Vashon Island at 0738.
After embarking 75 passengers and loading 8 vehicles, the vessel undocked and departed Vashon Island about 0803, 8 minutes behind the scheduled departure time, for its 2.8-nautical-mile return eastbound transit. The quartermaster was at the helm in the no. 2 pilothouse. According to the quartermaster, the master on watch arrived in the no. 2 pilothouse about 2 minutes later, at 0805.
The quartermaster remained at the helm as the ferry transited at 17.6 knots across Puget Sound on a course between 70° and 75° between Vashon Island and Fauntleroy. The quartermaster told investigators that after the master arrived in the pilothouse, the master initially sat in the desk chair located on the port side of the space, aft. The master took control of the ferry about 0810, before it was a half mile away from the Fauntleroy Ferry Terminal, to start preparing for the maneuver to dock the vessel.
After handing helm control to the master, the quartermaster moved away from the helm and became focused on reading a company memo near the chart table, about 10 feet aft of the helm. During this time, he was not watching the vessel’s progress as it approached the ferry terminal.
With the no. 1 engine in operation for the eastbound transit (effectively the stern for the transit), the master called the engine room about 0812, according to the engine room logbook, to request that engine no. 2 be engaged so the propeller (bow for the transit) could be operated to help slow the vessel as it approached the ramp at the ferry dock. The engineer on watch confirmed that engine no. 2 was engaged.
According to the vessel’s Data Logger, which monitored the helm and throttle controls, over about the next minute, a series of rudder commands was given, generally from about midships up to 15° starboard. At 0812:52, a final 15° rudder command to starboard was made, followed by stepped adjustments, before the rudder was ordered and reached midships at 0813:19, when the ferry was about a third of a mile from the terminal ramp. There were no other helm or throttle commands noted. The US Coast Guard Vessel Traffic Service radar showed the Cathlamet turning to starboard while slowing from 17.6 knots to about 15.7 knots. Over the next 28 seconds, the vessel’s heading continued to move to starboard as the Cathlamet approached the dock. The vessel’s Automatic Identification System (AIS) data showed the Cathlamet on an easterly heading of 88° at 0813:27, which was bringing the Cathlamet to the south of the terminal. At 0813:37 the vessel’s heading was at 90°. At 0813:45, it had a heading of 92°, was still to the south of the terminal, and was proceeding at 15.7 knots.
The quartermaster told investigators that he felt something was not right, looked up, saw that the vessel was off course, and started to walk toward the master. “There should have been more of a slowdown. It ... should have taken longer to the dock. It just didn’t feel right,” he said.
At 0813:46, the Data Logger recorded a no. 1 (stern) rudder order of 35° to port, and the rudder angle reached 27° a few seconds later. The camera footage from on board the vessel and at the ferry terminal showed the vessel’s port bow striking a ferry terminal dolphin on the south side of the terminal at 0813:47.3 Coast Guard Vessel Traffic Service data showed the vessel was still at 15.7 knots at impact. The dolphin was about 190 feet west and about 35 feet south of the center of the ramp where the ferries docked.
A passenger who had been standing on the portside passenger deck forward saw that the vessel was about to strike the dolphin and started to move aft toward the house. When the ferry struck the dolphin, the area where he had been standing collapsed from the impact. He hung onto a railing, which prevented him from falling onto the damaged deck below. When the deck collapsed, the port passenger deck structure also folded onto the car deck and penetrated the interior of a parked car, just missing the occupant who was sitting in the driver’s seat.
After the ferry struck the dolphin, the vessel continued to move forward toward the shore where recreational vessels were anchored. The quartermaster told investigators that the master looked at him, asking twice, “what happened?” Realizing that the vessel was still moving forward and possibly could strike the anchored vessels or run aground, the quartermaster told the master to “back out.” He told the master to back out two more times, before the master engaged both engines and stopped the vessel’s forward motion—actions that were recorded in the Data Logger.
Shortly after the contact, the master of the other (resting) deck watch section arrived in the pilothouse, took control of the vessel, and maneuvered it to the ferry terminal. The crewmembers from both deck watches and the engineers completed a safety check of the passengers and assessed the damage to the vessel as it docked at the terminal at 0820. The passengers and vehicles departed the vessel about 0930, once the ferry was safely docked and emergency medical services personnel checked passengers for injuries."