Fatigue and a lack of sleep likely caused the master of the ferry Cathlamet to briefly nod off and lose control of the vehicle right before its 2022 crash into pilings near the Fauntleroy terminal, according to a report released Oct. 12

The report, authored by the National Transportation Safety Board (NTSB), found “fatigue and complacency” were to blame for the collision, as the master steering the ferry had been running on five to six hours of sleep and dealing with a family member’s deteriorating health.

It also raised concerns that due to complacency, the ferry’s bridge team did not step in sooner to prevent the crash.

The report also reveals the crash’s fortunate lack of more serious injuries; it detailed how one passenger held on to a railing to avoid falling to the deck, and how a car passenger narrowly avoided being struck by a chunk of deck that smashed through the back and side of their car.

The Cathlamet ferry struck a collection of protective pilings known as a mooring “dolphin” on Thursday, July 28 that year, near the Fauntleroy Ferry Terminal. It had left Vashon around 8:03 a.m. The crash caused extensive damage to the ferry, leaving one car pinned in the top left part of the boat.

The crash ultimately led to one minor injury, $6.7 million in damages to the ferry, according to WSF, and $300,000 in damages to the pilings it struck, according to the report.

The report is the second of three investigations into the crash to resolve. WSF issued its own internal report in March, and the U.S. Coast Guard’s investigation is not yet finished.

WSF has new policies and training procedures, according to the agency, and “black box” vessel data recorders have been installed on the Cathlamet and will become standard on all WSF vessels.

“Safety is Washington State Ferries top priority, and WSF has a lengthy and proven safety record,” WSF said in a prepared statement. “WSF thanks the NTSB for their support and findings which essentially verify the results of our internal investigation which was released in March.”

Spokespersons for the WSF did not respond to questions about the specifics of those new policies by press time.

Timeline of crash

Crossing the Puget Sound, the ferry had left Vashon’s north end and was heading toward the Fauntleroy terminal near West Seattle the morning of the crash. The quartermaster had the helm until about 8:10 a.m., when the master took control to begin preparing for docking.

Two minutes later, at 8:12 a.m., the master called to the engine room to begin the process of slowing the vessel as it approached the ramp. But the master stopped rudder commands about 30 seconds before the 8:14 a.m. crash, according to the NTSB.

Moments before the crash, the quartermaster told investigators, he felt that something was wrong, noticed the vehicle was off course and walked over to the master.

Data from the ferry showed a stern rudder order to turn to port (left) was issued exactly one second before the crash at 8:13:47 a.m., according to the report — too late to prevent the collision with the right-side dolphin on the ferry’s left-hand side.

“The master did not take any action to correct the ferry’s course, slow down or sound the alarm before the contact,” reads the report. “He also did not recall what happened and seemed unaware of how the ferry ended up striking the dolphin. Investigators found these events were all consistent with incapacitation from a microsleep, a brief period of sleep lasting a few seconds, due to fatigue.”

The report also raised performance issues with the ferry’s bridge team, who did not comply with policy when undocking and docking the ferry. The quartermaster was reading a company memo after handing the helm to the master instead of monitoring the vessel’s approach to the terminal, according to the report.

“The Cathlamet quartermaster did not actively monitor the master as the ferry approached the dock, as required by company policy,” the report reads. “Had he done so, he could have quickly taken the helm when the master became incapacitated.”

After the crash, the master twice asked the quartermaster “What happened?” according to the report. Realizing the vessel was still moving toward the coastline after the crash, the quartermaster told the master to “back out” — repeating the request two more times before the master engaged both engines and finally stopped the vessel’s forward motion.

Shortly after, a master from the other deck watch section took control of the vessel and maneuvered it to the terminal. The vessel docked at the terminal at 8:20 a.m., and passengers finally departed at 9:30 a.m.

Aftermath

The ferry had 94 people on board, and one person suffered a minor injury from the crash, according to the NTSB report.

But two far more serious injuries were just narrowly avoided.

“When the ferry struck the dolphin, the area where (a passenger) had been standing collapsed from the impact,” according to the report. “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.”

Fauntleroy’s dock re-opened for service by late afternoon, with another WSF vessel, the Kitsap, replacing the Cathlamet. But a mechanical problem beset the Kitsap soon after its arrival at the dock, temporarily reinstating one-boat service and making for an overall miserable day for island commuters.

The master, a seaman who began work for WSF in 1985, tested negative for alcohol and other drugs, and a review of cell phone records found he was not using his phone before or during the crash.

The master had been working the same shift on the ferry for about six months.

His 96-hour work/rest history, however, showed he had been sleeping for five to six hours per night before the crash, arriving at the ferry around 3:30 a.m. each morning and assuming watch around 7:20 a.m. Asked about the master’s demeanor when arriving on the Cathlamet, the quartermaster told investigators he was typically “always tired in the morning.”

The morning of the crash, the quartermaster said, the master “just seemed tired.”

The master told investigators he’d been bothered at the time by a family member’s medical condition, and his sleep also seemed to be affected by a heatwave in the region at the time.

The master retired from WSF the day after the crash and declined to provide more information to investigators.

NTSB investigators stressed in their report that when mariners are fatigued, they must arrange for a qualified person to serve in their place, so they can avoid working on duty in a state that could risk passenger, crew or vessel safety.

They also wrote that complacency must be reduced via training and vigilance of procedures, noting that repetitive operations, such as back-and-forth trips on ferry routes, particularly require operators to keep vigilant against complacency.

To read the full 18-page report, go here.