A case where crew fatigue caused the grounding of a vessel in the Bulgarian Coast.
On 20 September 2021, a general cargo ship ran aground on the rocky coast of the Yailata protected area in Bulgaria. The incident occurred when the ship, traveling from Yuzhniy, Ukraine, to Varna, Bulgaria, deviated from its planned course because the second officer (2/o) on watch fell asleep. The bridge navigational watch alarm system (BNWAS) was found deactivated, removing a critical safety net.
The investigation by the Bulgarian National Air, Maritime, and Rail Accident Investigation Board (NAMRAIB) concluded that fatigue, insufficient lookout arrangements, and lapses in the ships safety management system (SMS) contributed significantly to the incident.
Summary of the incident
At midnight on 20 September 2021, the 2/O relieved the master to take over the 0000 to 0400 navigational watch. However, contrary to the SMS and international regulations, no additional lookout was assigned for the night watch. The BNWAS, designed to alert the crew if the officer on watch becomes incapacitated, was turned off. During the night, the ship proceeded on autopilot. The 2/O conducted his watch normally.
However, between 0345 and 0355, he briefly sat on the bridge’s couch and fell asleep. This lapse proved critical. At 0353, the ship failed to execute a planned turn to join the TSS and continued a straight course towards the shoreline. Coastal authorities monitoring the ship attempted to call on Very High Frequency (VHF) radio when it did not alter course, but the 2/O failed to respond.
At around 0413, the ship ran aground at a speed of 7.8 knots in the Yailata Protected Area, causing extensive hull damage. Water entered several ballast tanks through breaches in the hull, but there was no immediate fuel leakage. The impact rendered the ship immobile, and the rocky bottom complicated subsequent refloating efforts.
Lessons learned
Improved fatigue management and watchkeeping
The incident emphasises the need for strict fatigue management policies to ensure that all officers and crew members are sufficiently rested before taking on critical watchkeeping duties. Companies must implement adequate rest periods and avoid assigning excessive administrative or non-navigational duties to watchkeeping officers. A dedicated lookout during all watches, particularly in high-risk areas like the TSS, is essential to maintaining navigational vigilance and minimising human error risks.
BNWAS and safety equipment adherence
The incident highlights the importance of ensuring that all safety equipment, particularly the BNWAS, always remains operational. This system plays a crucial role in monitoring the alertness of watchkeepers and should never be disabled, especially during solo watches. Regular audits and system checks can prevent lapses in equipment usage and ensure that essential devices are always in working order to safeguard against accidents.
Communication and response protocols
The delay in responding to coastal authorities after the grounding impacted the immediate response efforts. This incident underscores the importance of swift communication between ships and local authorities to expedite emergency assistance. The SMS should include clear protocols for rapid reporting and cooperation with coastal authorities in case of emergencies to avoid delays and minimise potential risks to the crew, ship, and environment.
Bridge team management and communication
Proper bridge management requires not only monitoring equipment but also maintaining a vigilant lookout. The absence of a lookout on the bridge significantly increased the risk of human error.
Importance of documentation and oversight
Finally, the ship grounding incident highlights the necessity for meticulous route documentation and strict adherence to SMS protocols. Any course deviations should be documented, approved by the master, and communicated to all relevant parties to ensure safety. These procedures are vital for maintaining accountability and providing a clear action plan during unexpected navigational challenges.
Full advisory at the following link.
https://safety4sea.com/wp-content/uploads/2025/02/Britannia-BSafe-Case-Study-26-2025_02.pdf