An investigation into a near-miss incident where the cargo vessel Kairit veered off course and approached the Danish coast while its chief officer fell asleep on the bridge.
The incident
On 12 October 2024, at 2200, the cargo vessel Kairit departed from Mukran, Germany, carrying 4,400 metric tonnes of wheat, bound for Immingham, UK. At departure, the master was on watch, later handing over to the chief officer at midnight. At 0505, Kairit entered the traffic separation scheme (TSS), a designated shipping lane to reduce collision risk, off Falsterbro, proceeding westbound at eight knots. The chief officer, seated on the bridge, fell asleep after sending an AB (Able Seaman) for a routine safety check.
At 0650, when the vessel was 1.5 nm off course, heading toward Stevns Klint, Denmark, the master arrived on the bridge, finding alarms ringing and the chief officer asleep. He promptly corrected the course and responded to the calls.
It was later discovered that the bridge navigational watchkeeping alarm system (BNWAS), a system that alerts the officer of the watch if inactive, was switched off.
Fatigue
The chief officer’s work / rest hour records indicated that his rest periods met the requirements of the Seafarers’ Training, Certification and Watchkeeping (STCW) Code, as amended. However, the safety investigation was unable to verify the quality of these rest periods, in terms of uninterrupted, good quality sleep. The master and the chief officer were on contracts of two months on board and two months of vacation leave.
The Company explained that these arrangements were in place to minimize the chances of fatigue, in consideration of the vessel’s short voyages. While the chief officer confirmed feeling tired around the time of the occurrence, the safety investigation had no strong and clear indications of fatigue.
Rather, he actually reported feeling fresh and well rested on the following morning, after getting his scheduled rest. The safety investigation was also informed that there were no other instances of recurrence during the rest of the voyage.
The safety investigation lacked the necessary information to analyze the factors associated with fatigue, albeit it was not dismissed. The unavailability of information on hours of quality sleep meant that the possibility of sleep deprivation on board, being a chronic concern, could not be analyzed in detail.
The available information indicated that the chief officer felt well rested the following morning, with no further reported issues. A prima facia, this could suggest that the sleep deprivation, which the chief officer had experienced, could have been a short-term issue, affecting one particular very early morning.
Sleep deprivation can happen either because of lack of sleep hours, or else because of lack of good quality sleep. Sleep duration and sleep quality are important to ensure restorative sleep, and although there was no information on potential long-term sleep deprivation, the safety investigation was of the view that this was not to say that the crew members had not experienced instances of tiredness. In fact, the OOW (Officer of the Watch) falling asleep in his chair on the bridge during his watch, may be considered as one such instance.
Therefore, while the chief officer appeared well-rested the following morning, this alone did not eliminate fatigue as a contributing factor. Fatigue can be cumulative, and one night of good rest does not negate the effects of prior sleep loss.
A more comprehensive assessment of overall sleep patterns, workloads, and other signs of fatigue, would have been necessary. In the absence of such data, the safety investigation did not dismiss fatigue solely on the basis of a mere reported instance of restfulness following the incident.
Sole lookout and the BNWAS
The information available to the safety investigation suggested that the crew member was asleep and the various calls on the bridge did not wake him up. The master recalled that as soon as he entered the bridge, he could hear the vessel’s mobile phone ringing, VHF DSC alarms, and frequent VHF radio calls to the vessel. The lookout had left the bridge at about 0540, and the master arrived at approximately 0650.
Assuming that the OOW sat on the chair soon after the lookout left the bridge and was fast asleep minutes later, it can be concluded that he had been asleep for approximately one hour before the master arrived on the bridge. Dividing the sleep cycle into four stages, it was highly probable that the OOW was in stage 3 of the cycle, i.e., in the deep sleep part during which, it would have been very hard for him to wake up.
When the chief officer had sent the AB from the bridge for the routine safety round and sounding of the cargo hold bilges, it was twilight. Moreover, at the time, the vessel was navigating in a TSS.
The absence of the lookout from the wheelhouse may be interpreted in two distinct but not necessarily mutually exclusive ways. On one hand, it could suggest a normalisation of deviance i.e., a possible erosion of the perceived criticality of the lookout role, where routine practices begin to drift from procedural expectations. On the other, it may reflect a situational necessity, where the OOW faced competing demands, i.e., the requirement for safety rounds in the accommodation, leading to a context-driven decision, influenced from what seemed necessary at the time.
Rather than viewing this as a failure of compliance with prescribed international maritime requirements, the safety investigation considered this as an example of adaptive behaviour under system constraints. For the purpose of the safety investigation, the lookout’s absence is thus less a sign of ‘complacency’ and more a symptom of systemic pressures that challenge the capacity for safe performance by the OOW across multiple, simultaneous responsibilities.
Additionally, as was the case in several past grounding accidents investigated by the MSIU and other accident investigation authorities, Kairit’s BNWAS was also switched off. Here, too, it appeared that the unavailability of the BNWAS, as a preventive barrier system, was not a concern for the crew members.
The absence of a lookout and the unavailability of the BNWAS were, therefore, considered as contributory factors to this occurrence.
Conclusions
- Kairit was at risk of running aground during a lapse in active navigational watch and during which, the officer on watch inadvertently fell asleep.
- The grounding was avoided by the master’s timely actions, when he happened to go to the bridge to take over the navigational watch.
- The OOW recalled that after 0500, he started feeling tired, so he sat on the port side bridge chair.
- Although the OOW felt rested after a night’s sleep, fatigue was not dismissed.
- The OOW last rest period before the incident was only two hours and may have not provided him with adequate rest to keep a sharp watch for the next seven hours.
- The bridge BNWAS was switched off at the time of the incident.
- There was no lookout on the bridge when the OOW fell asleep.
- The manning levels on board may have not addressed the reality of the vessel’s operations, be it cargo, and / or navigation, even if they met the requirements of the Minimum Safe Manning certificate issued by the flag State Administration.
- While exemptions were initially justifiable, it was critical for the flag State Administration to anticipate a potential deterioration in compliance, to avoid an eventual reactive rather than proactive regulatory approach.
- The vessel had a limitation on the number of crew members which could be signed on board because of unavailable space in the accommodation block.
Safety actions taken during the course of the safety investigation
Following the incident, the Company took the following actions:
- The crew composition has been amended to ensure a more effective bridge team, consisting of a master, chief officer and one OOW;
- The vessel was attended by the Company’s Safety & Quality Manager to provide target training to the crew members on safe practices related to this occurrence;
- Verification of compliance with BNWAS operating procedures has been incorporated as a mandatory check during internal audits and superintendent inspections across all fleet vessels.
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