200240 Fatigue starts Error Chain

Fatigue starts Error Chain
Report No. 200240

After an eighteen hour day, including a Panama Canal transit, and during which time, between locks, I had to make innumerable trips to my office five decks below to receive, clarify and confirm the vessel's ability to lift a new cargo nomination at a port just eight hours steaming from the canal exit, I went to the bridge to write my night orders. Due to a combination of tiredness and the vessel's vibration, which make any writing on the chart table almost impossible, my hand written orders to give the engine room "one hours notice

EOP (End of Passage)", were interpreted as "one hours notice

Fortunately, when I went to the bridge in the early hours of the morning, and fifteen minutes before arrival at the designated EOP position, there was sufficient sea room to take a slow round turn whilst the engine speed was reduced for manoeuvring. I could not blame the OOW for my bad writing, but we did have a heart to heart discussion about the application of common sense.

This is an excellent example of what MARS is all about. Somebody actually confessing that an error had occurred which could have led to serious consequences. It also shows how fatigue can affect the everyday operations of a ship when, as often happens, there was no opportunity for proper rest.