The Importance of Rest Hours: Lessons from the M/V Alfred Grounding

 Is Human Error Intentional or Unintentional? 

By Capt.Nishant Mehta

The Tragedy of "Fri Sea": A Wake-Up Call

On the evening of 28 March 2024, the "Fri Sea", a Bahamas-flagged coastal cargo vessel, left Groveport, UK, having successfully discharged its cargo. It was a routine departure until preparations began for the pilot’s disembarkation.

Two crew members were assigned the task of rigging the pilot ladder. Once completed, one seafarer returned to the accommodation while AB2, a 58-year-old sailor, stayed back on deck for a cigarette. Moments later, when the master called AB2 to signal the pilot’s readiness to disembark, there was no response.

An immediate search was initiated. By 22:50, the pilot was informed of a suspected man overboard. The vessel stopped, and rescue efforts began, with the pilot boat, air, and sea rescue teams joining the search. Tragically, AB2’s body was discovered hours later onshore—without a lifejacket. 

The post-mortem revealed that acute myocardial ischemia (blocked blood flow to the heart), compounded by ischemic heart disease (weakening of the heart due to reduced blood flow) and severe coronary artery atheroma (buildup of fatty deposits inside coronary arteries), led to the tragic loss of AB2, highlighting how underlying health issues intersect with unsafe practices.

This incident is not just a tragic loss of life; it exposes the fragility of human actions, the gaps in safety protocols, and the stark reality of how intentional and unintentional human errors intertwine to create catastrophic outcomes.

Coutersy : Bahamas Maritime Authority Investigation report

The fixed door on the railing opens inwards when rigging a pilot ladder with no additional securing measures for the open railings.

Human Error: Unpacking the Causes

Human error remains one of the most cited causes of maritime accidents. From slips and lapses to mistakes and violations, each form of error sheds light on how decisions and actions can go awry, often with devastating consequences.

Let’s analyze the Fri Sea tragedy through the human error theory and the balance between intentional and unintentional errors.

1. Unintentional Actions: Errors in Execution

Unintentional errors occur when actions don’t align with intentions. In this case, AB2's actions offer examples of both:

• Slips: While staying on deck, AB2 might have been distracted, possibly focusing more on his cigarette than on his proximity to the open railing. 

• Lapses: The absence of a checklist or communication protocol for ensuring personal safety—such as wearing a lifejacket or using fall protection—suggests a memory or procedural gap. A lapse in attention can prove fatal, especially in high-risk areas.
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• 2. Intentional Actions: Errors in Planning

Intentional errors arise from actions executed as planned but inappropriate for the context.

• Mistakes: The failure to mandate lifejackets or ensure fall protection demonstrates poor risk assessment. While the actions were deliberate, they were misaligned with safe operational practices.

• Violations: If AB2 knowingly bypassed safety protocols, this points to a routine violation, likely stemming from complacency or an ingrained culture of ignoring safety measures.

Performance Levels and Failure Modes

Human performance operates at three levels, each susceptible to errors that compound during high-risk scenarios like that on the Fri Sea.

1. Skill-Based Performance

Skill-based actions rely on habitual routines.

• AB2, an experienced sailor, may have trusted his instincts and experience, overlooking the need for safety equipment due to familiarity with the task.
• Fatigue, especially after returning from an 80-day leave just a day earlier, could have impaired his ability to remain vigilant, leading to inattention.

2. Rule-Based Performance

Rule-based actions depend on adherence to established protocols.

• The crew’s failure to ensure adherence to lifejacket rules indicates either a misapplication of good rules or reliance on bad rules, likely due to operational complacency.
• Without explicit reinforcement of fall prevention measures, the crew’s decision-making was inherently flawed.

3. Knowledge-Based Performance

Knowledge-based actions are required when no clear rules apply, often under stress or uncertainty.

• The absence of a contingency plan for managing fall risks during non-routine moments highlights knowledge gaps.
• Fatigue and limited situational awareness likely influenced AB2’s reliance on heuristics (mental shortcuts), which proved inadequate for the situation.

Top ten human error precursors (error traps): 

• Stress
• High work load
• Time pressure 
• Poor communications
• Vague or poor work guidelines
• Overconfidence concerning work and or abilities
• First time performing the task
• Distractions
• First working day following time off
• 30 minutes after a meal or waking up

Lessons Learned: A Safer Way Forward

The "Fri Sea" tragedy teaches us valuable lessons about improving safety and preventing similar incidents:

1. Prevent Fatigue

   • Ensure crew members are well-rested, especially after long leave.
   • Plan work schedules to avoid overwork and stress.

2. Follow Safety Rules

   • Always wear lifejackets and use fall protection near open railings even if working on main deck.
   • Regularly practice safety drills to make sure everyone follows the rules.

3. Build Risk Awareness

   • Train crew members to recognize unsafe situations before they escalate.
   • Create a culture where safety concerns are openly discussed and addressed.

4. Communicate Clearly

   • Use clear instructions for tasks and emergencies.
   • Make sure every team member knows their role and is ready to act in critical moments.

Simple changes like these can save lives and prevent future tragedies, reminding us that safety begins with everyday actions.

Conclusion: Closing the Circle

The "Fri Sea" tragedy reminds us of the need to strengthen safety practices and address human limitations. By fostering a strong safety culture, reducing fatigue, and learning from past mistakes, we can create safer maritime operations. Ultimately, through resilience and adaptation, we ensure that the legacy of those we’ve lost is one of progress and safety for all who navigate the seas.

Acknowledgements:

This blog is based on information from various sources that help us understand safety and human factors in maritime operations. We would like to thank:

• The Bahamas Maritime Authority for their detailed investigation report on the Fri Sea. 
• Incident investigation report of "Fri Sea"
  
• The International Atomic Energy Agency for their Human Performance Module, which explains how human actions affect safety. 
• Wikipedia and other publicly available sources for their useful insights on safety and human factors.

These resources have been invaluable in creating this article and promoting safety awareness in the maritime industry.

Disclaimer:

The information provided in this blog is for educational and awareness purposes only. While every effort has been made to ensure accuracy, this content should not be considered a substitute for official guidelines, safety protocols, or professional advice. The opinions expressed are those of the author and do not necessarily reflect the views of any specific organization or regulatory body. Readers are advised to consult relevant authorities or experts for specific operational or safety concerns.