Collision of Tankship Eagle Otome with Cargo Vessel Gull Arrow and subsequent collision with the Dixie Vengeance towboat in the Sabine-Neches Canal in Port Arthur, Texas, January 23, 2010

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Synopsis

This is a synopsis from the Safety Board's report and does not include the Board's rationale for the conclusions, probable cause, and safety recommendations. Safety Board staff is currently making final revisions to the report from which the attached conclusions and safety recommendations have been extracted. The final Report and pertinent safety recommendation letters will be distributed to recommendation recipients as soon as possible. The attached information is subject to further review and editing.

Executive Summary

On Saturday, January 23, 2010, about 0935 central standard time, the 810-foot-long oil tankship Eagle Otome collided with the 597-foot-long general cargo vessel Gull Arrow at the Port of Port Arthur, Texas. A 297-foot-long barge, the Kirby 30406, which was being pushed by the towboat Dixie Vengeance, subsequently collided with the Eagle Otome. The tankship was inbound in the Sabine-Neches Canal with a load of crude oil en route to an ExxonMobil facility in Beaumont, Texas. Two pilots were on board, as called for by local waterway protocol. When the Eagle Otome approached the Port of Port Arthur, it experienced several unintended heading diversions culminating in the Eagle Otome striking the Gull Arrow, which was berthed at the port unloading cargo.

A short distance upriver from the collision site, the Dixie Vengeance was outbound with two barges. The towboat master saw the Eagle Otome move toward his side of the canal, and he put his engines full astern but could not avoid the subsequent collision. The Kirby 30406, which was the forward barge pushed by the Dixie Vengeance, collided with the Eagle Otome and breached the tankship's starboard ballast tank and the No. 1 center cargo tank a few feet above the waterline. As a result of the breach, a total of about 862,344 gallons of oil were released from the cargo tank, and an estimated 462,000 gallons of that amount spilled into the water. The three vessels remained together in the center of the canal while pollution response procedures were initiated. No crewmember on board any of the three vessels was injured.

Findings

  1. Weather, mechanical failure, and illegal drug or alcohol use were not factors in the accident.
  2. The vessel meeting arrangement agreed to by the towboat master and the first pilot was appropriate and was not a factor in the accident.
  3. Personnel at Vessel Traffic Service Port Arthur played no role in the accident.
  4. The Eagle Otome pilots did not follow Sabine Pilots Association guidelines with respect to division of duties while under way.
  5. Although both pilots completed bridge resource management training, they failed to apply the team performance aspects of bridge resource management concepts to the operation.
  6. Contrary to pilot association guidelines, the first pilot on the Eagle Otome was conducting a radio call at a critical point in the waterway, and the radio call interfered with his ability to fully focus on conning the vessel.
  7. Had the Eagle Otome pilots alerted the Dixie Vengeance master of the sheering problem, the force of the collision between the Eagle Otome and the Dixie Vengeance tow would have been lessened or the collision may have been avoided altogether.
  8. The combination of untreated obstructive sleep apnea, disruption to his circadian rhythms, and extended periods of wakefulness that resulted from his work schedule caused the first pilot to be fatigued at the time of the accident.
  9. The first pilot's failure to correct the sheering motions that began after his late turn initiation at Missouri Bend led to the accident.
  10. The first pilot's fatigue adversely affected his ability to predict and stop the Eagle Otome's sheering.
  11. No effective hours of service rules were in place that would have prevented the Sabine pilots from being fatigued by the schedules that they maintained.
  12. The absence of an effective fatigue mitigation and prevention program among the pilots operating under the authority of the Jefferson and Orange County Board of Pilot Commissioners created a threat to the safety of the waterway, its users, and those nearby.
  13. The Jefferson and Orange County Board of Pilot Commissioners should have more fully exercised its authority over pilot operations on the Sabine-Neches Waterway by becoming aware of and enforcing the Sabine Pilots Association's two-pilot guidelines and implementing a fatigue mitigation and prevention program among the Sabine pilots.
  14. The Coast Guard is the organization with the resources, capabilities, and expertise best suited to (1) enhance communication among pilot oversight organizations and (2) establish an easy to use and readily available database of pilot incidents and accidents.
  15. The first pilot's sounding the Eagle Otome's whistle and the Gull Arrow master's sounding the cargo vessel's general alarm were prudent and effective.
  16. The accident response and oil spill recovery efforts were timely and effective.
  17. The dimensions of the Sabine-Neches Waterway may pose an unacceptable risk, given the size and number of vessels transiting the waterway.
  18. 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.
  19. Consistent use of a vessel's name in radio communication can help avoid confusion and enhance bridge team coordination.

Probable Cause

The National Transportation Safety Board determines that the probable cause of the collision of tankship Eagle Otome with cargo vessel Gull Arrow and the subsequent collision with the Dixie Vengeance tow was the failure of the first pilot, who had navigational control of the Eagle Otome, to correct the sheering motions that began as a result of the late initiation of a turn at a mild bend in the waterway. Contributing to the accident was the first pilot's fatigue, caused by his untreated obstructive sleep apnea and his work schedule, which did not permit adequate sleep; his distraction from conducting a radio call, which the second pilot should have conducted in accordance with guidelines; and the lack of effective bridge resource management by both pilots. Also contributing was the lack of oversight by the Jefferson and Orange County Board of Pilot Commissioners.

Recommendations

To the U.S. Coast Guard

1. (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)

2. 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)

3. Facilitate and promote regular meetings for representatives of pilot oversight organizations to communicate information regarding pilot oversight and piloting best practices. (M-11-XX)

4. 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

5. 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

6. 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:

7. 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)

8. 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)

9. 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

10. 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

11. 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

12. 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)

Safety Recommendation M-09-5 (previously classified "Open-Unacceptable Response") is classified "Closed-Unacceptable Response/Superseded" by recommendations 3 and 4 above.