Contributing to the collisions, which caused an estimated 462,000 gallons of oil to spill into the Sabine-Neches canal, was the first pilot's fatigue, caused by his untreated obstructive sleep apnea and his work schedule, which did not permit time for adequate sleep; and his distraction from conducting a radio call, which the second pilot should have handled in accordance with guidelines; and the lack of effective bridge resource management by both pilots. Also contributing to the accident was lack of oversight by the Jefferson and Orange County Board of Pilot Commissioners.
Other findings included:
The dimensions of the Sabine-Neches Waterway may pose an unacceptable risk, given the size and number of vessels transiting the waterway.
Commonly accepted human factors principles were not applied to the design of the Eagle Otome's engine control console, which increased the likelihood of error in the use of the controls.
Consistent use of a vessel's name in radio communication can help avoid confusion and enhance bridge team coordination.
"The NTSB has long been concerned about fatigue in the marine industry, and this accident highlights the very real consequences of degraded performance," said NTSB Chairman Deborah A.P. Hersman. "Additionally, guidelines for operating in this tricky stretch of waterway were established 30 years ago to increase the margin of safety and offset human error, but unfortunately, in this accident, they were not followed."
As a result of this accident, the NTSB issued 10 new safety recommendations to the U.S. Coast Guard, the Jefferson and Orange County Board of Pilot Commissioners, the Sabine Pilots Association, the governors of states and territories in which state and local pilots operate, and the American Pilots' Association. The Safety Board also reiterated a previously issued recommendation to the U.S. Coast Guard.
To the U.S. Coast Guard
- (1) Conduct a ports and waterways safety assessment for the Sabine-Neches Waterway, (2) determine from that whether the risk is unacceptable, and if so, (3) develop risk mitigation strategies. (M-11-XX)
- Work through the International Maritime Organization to encourage the application of human factors design principles to the design and manufacture of critical vessel controls. (M-11-XX)
- Facilitate and promote regular meetings for representatives of pilot oversight organizations to communicate information regarding pilot oversight and piloting best practices. (M-11-XX)
- Establish a database of publicly available pilot incidents and accidents and make the database easy to use and readily available to all pilot oversight organizations. (M-11-XX)
- To the Jefferson and Orange County Board of Pilot Commissioners
- Develop and implement (1) a system to monitor your state-licensed pilots so that your commission can verify the execution of policies, procedures, and/or guidelines necessary for safe navigation, and (2) a fatigue mitigation and prevention program among the Sabine pilots. (M-11-XX)
To the Sabine Pilots Association
- Take action to ensure that your member pilots follow your guidelines with respect to division of duties and responsibilities of pilots. (M-11-XX)
To governors of states and territories in which state and local pilots operate:
- Ensure that local pilot oversight organizations effectively monitor and, through their rules and regulations, oversee the practices of their pilots to promote and ensure the highest level of safety. (M-11-XX)
- Require local pilot oversight organizations that have not already done so to implement fatigue mitigation and prevention programs that (1) regularly inform mariners of the hazards of fatigue and effective strategies to prevent it, and (2) promulgate hours of service rules that prevent fatigue resulting from extended hours of service, insufficient rest within a 24-hour period, and disruption of circadian rhythms. (M-11-XX)
- Require local pilot oversight organizations that have not already done so to implement initial and recurring bridge resource management training requirements. (M-11-XX)
To the American Pilots' Association
- Advise your members to consistently identify vessels by name in bridge-to-bridge radio communication, as required by the Federal Communications Commission. (M-11-XX)
Previous Recommendations Reiterated in This Report
To the U.S. Coast Guard
- Require mariners to report to the Coast Guard, in a timely manner, any substantive changes in their medical status or medication use that occur between required medical evaluations. (M-09-4)
Previously Issued Recommendation Classified in This Report
To the U.S. Coast Guard
- Establish a mechanism through which representatives of pilot oversight organizations collect and regularly communicate pilot performance data and information regarding pilot oversight and best practices. (M-09-5)
September 28, 2011