The Grounding of the Exxon Valdez
On March 24 1989, the VLCC Exxon Valdez (214,861dwt, age three years) was carrying about 200,000 tons of crude oil, and ran aground on Bligh Reef in the Prince William Sound of Alaska. Approximately 41,000KL of oil was spilled, which affected 2,400km of Alaskan coastline. This was the largest marine pollution crisis on the U.S. coast. The total cost of loss, inclusive of cleaning up operations, exceeded the amount of USD 2.5bio. Following this accident, the IMO studied ways to prevent this type of incident from happening again. One result was tighter requirements for double hulls on tankers.
Figure 1: Area between the terminal and the grounding
2235 Exxon Valdez arrived at the terminal.
0505 Loading of crude oil started.
1030 The master, chief engineer and radio electronics officer went ashore.
1924 Cargo loading operations were completed (200,500mt).
2020 The pilot boarded the vessel; two tugs were used.
2030 The master returned to the vessel.
2100 The master, chief mate and pilot started preparations on the bridge for departure.
2112 All mooring lines were removed and the vessel moved away from the berth.
2121 The vessel was clear of the berth and one tug started escorting the vessel.
The third mate relieved the chief mate (3/O).
2324 The pilot departed the vessel off Rocky Point.
2325 The master informed the Coast Guard Vessel Traffic Center (VTC) that he was increasing speed to 16 knots.
2326 To avoid the ice floe in the vessel’s path, the vessel crossed the inbound lane.
The master informed the VTC that the vessel might depart the traffic lanes.
2331 The master again called the VTC regarding ice in the traffic lanes.
The course was changed to 200° and speed was reduced to 12 knots.
2339 Changed course to 180°.
2350 As ordered by the master, the helmsman engaged the automatic pilot when the vessel’s heading was steady on 180° by pressing the Gyro button (according to testimony of helmsman).
2352 The master informed the third mate that he (the master) would leave the bridge to send messages and that he wanted the third mate to start returning the vessel to the traffic lanes when Busby Island Light was abeam to port.
The third officer determined that there was a distance of about 0.9 mile between Bligh Reef and the ice floe.
The third mate pressed the hand steering button to switch to hand steering mode (according to testimony of third mate).
2355 The third mate took a visual bearing of Busby Island Light from the port wing when the light was abeam. He then plotted the fix on the chart.
2357 (estimated) According to the third mate, he ordered the helmsman to put the rudder to STBD 10°. He does not recall watching the rudder angle indicator to ensure that the rudder was actually applied. The third mate then telephoned the master to inform him that he (the third mate) had started to turn the vessel back toward the traffic lanes.
2359 The third mate noticed that the heading was not changing and ordered the rudder increased to STBD 20°.
0001 Although the vessel’s heading was swinging STBD, the radar indicated that the vessel was still following a 180° track. The third mate ordered hard STBD rudder .
0002 The master was notified of an emergency and then the ship contacted the bottom.
0009 The vessel ran aground (according to the course recorder printout).
Figure 2: Course of the Exxon Valdez
Findings of the National Transportation Safety Board (NTSB)
The NTSB findings consisted of 47 items concerning the activities and behavior of parties involved with this accident. Findings include the following items concerning the vessel.
- The master’s decision to depart from the TSS to avoid ice was probably reasonable.
- Navigating the Exxon Valdez between the ice field and Bligh reef, two officers were required by, at least, good and safe practices to be on the bridge, one with conning and one to fix the position frequently, to navigate the vessel safely.
- The master’s decision to leave the third mate in charge of the navigation watch was contrary to Federal regulations and Exxon policy and was improper given the course of the vessel.
- The master’s judgement was impaired by alcohol during the critical period the vessel was transiting Valdez Arm.
- The performance of the third mate was deficient, probably because of fatigue, when he assumed supervision of the navigation watch from the master about 2350.
- The third mate failure to turn the vessel at the proper time and with sufficient ruder probably was result of his excessive workload and fatigued condition, which caused him to lose awareness of the location of Bligh Reef.
- The vessel was in the red sector of Busby Island Light for several minutes before grounding, which afford a warning of the reef that apparently was not noticed by the third mate or the lookout.
- There were no rested deck officers on the vessel available to stand the navigation watch when the vessel departed from the Alyeska Terminal.
- Many conditions conducive to producing crew fatigue on the Exxon Valdez exist on other Exxon Shipping Company vessels because many are three-mate vessels, and because the company has pursued reduced manning procedures. Although Flag Administration’s Minimum Safe Manning requirements were met, Exxon Shipping Company did not exceed same, as good and safe practices entail.
- The Exxon Shipping Company did not adequately monitor the master for alcohol abuse after his alcohol rehabilitation program.
- Exxon Shipping Company did not have a sufficient program for employees who had chemical dependency problem.
- Exxon Shipping Company manning policies do not adequately consist the increase in workload caused by reduced manning.
The Exxon Valdez contacted the bottom and then ran aground about 10 minutes after the master left the bridge at 2352. Although there were many problems, as explained later in this report, this section takes a close look at the NTSB investigation concerning the events during these 10 minutes, which was the operation of the vessel that directly caused the accident.
1) Testimony of the third mate (3/O)
- He learned that the vessel was on automatic pilot at 2350. He did not discuss the reason the vessel was on automatic pilot with the master.
- When the master left the bridge, 3/O and the master did not look at the chart together to review what the master expected him to do.
- He expected to change course in a few minutes, he went to the steering stand and pushed the hand steering button, removing the vessel from automatic and placing it in hand steering. He observed the indicator on the console illumination, signifying that the steering system was in hand steering mode.
- He noticed the heading was not changing, he ordered the rudder increased to STBD 20.
- However he did not recall the position of rudder when he issued the order for STBD 20 rudder.
2) Testimony of the helmsman
(Several days after the accident)
- He was unable to recall whether the vessel was on autopilot when he relieved the 2000-2400helmsman.
(The Safety Board public hearing)
- He arrived on the bridge he observed the 2000-2400 helmsman push “gyro” button to place the vessel on automatic pilot.
- He was about to push the hand steering button to put the vessel in hand steering but the third mate pushed the “button”.
- The third mate was “panicky” when he gave the order for hard STBD rudder.
- He did not expect the hard STBD rudder because the vessel was swinging well and had already used some counter rudder to slow the vessel’s swinging as he was bringing the vessel to a course of either 235 or 245, but he could not recall which course was correct.
- He received only helm orders and had not received an order to come to any particular course.
3) Course recorder record
- Testimony by three persons confirmed that the vessel was on autopilot before it passed Busby Island Light.
- No change could be detected in the course recorder trace that could be definitely linked to a change from hand steering to autopilot and then back to hand steering.
- The steering wheel on the SRP-2000 steering console could be turned while the vessel was on autopilot without producing any effect on the steering and no alarm would sound.
- The helmsman, on receiving the order for STBD 10 rudder, could have turned wheel to 10, but actual rudder movement would not have occurred.
- The computer simulation found no evidence that the turn had been initiated by putting the rudder more than 10 to STBD. The turn to about 247 was made by an average of 4 to 5 degrees of STBD rudder.
- The third mate was apparently at the chart table 4 to 6 minutes after the vessel had passed abeam of Busby Island Light.
- Although the third mate testified that he ordered the rudder increased to STBD 20 rudder about 1 1/2 minutes after ordering the STBD 10, and then ordered the rudder increased to hard STBD about 2 minutes later, this sequence of rudder order could not be substantiated using the course recorder trace.
There are several contradictions in the testimony of individuals involved with the accident. However, the NTSB reached the following conclusions concerning the activities of the 3/O.
The delay in starting the turn was most likely owing to inexperience in ship handling and piloting, fatigue, or both.
Analysis of causes
Many organizations and individuals associated with this accident were involved with the causes of the accident. This section examines only the unsafe action and the unsafe condition of the master and officers.
1) Actions of the master
Testimony by several individuals state that the master consumed alcoholic beverages (beer, vodka) while on shore. But the amount of alcohol consumed is unknown.
Marine Safety Office investigators who boarded the vessel after the accident at around 0335 smelled alcohol on the master’s breath when they met him on the bridge. The investigating officer described the odor as the very strong smell of stale alcohol. The investigating officer found two empty beer bottles discarded in the wastebasket in the master’s stateroom. Although it was not confirmed that the former were consumed prior of after the incident.
This information indicates that the master’s navigation instructions were definitely affected to some degree by alcohol.
- Preliminary briefing and passage plan
The master returned to the Exxon Valdez 30 minutes before departure and immediately started preparations for the departure. There was no preliminary meeting about the passage plan with the officers and the pilot. Furthermore, after the pilot departed, the vessel left the Traffic Separation Scheme (TSS) due to an ice floe and entered the inbound lane. No actions (revision of course line on the chart or instructions to an officer) were taken concerning this change in the passage plan. This is one of the most critical problems among the numerous causes of the grounding.
- Leaving the bridge and instructions to the 3/O
A few minutes before entering the narrow channel, the master left the bridge and allowed the officer to navigate the vessel alone. This was strictly prohibited by, at least, safe/ good practices procedures and was a major cause of the accident.
Furthermore, when the master left the bridge, he did not give the 3/O any clear instructions.
2) Actions of the 3/O
- Fixing of the vessel’s position
The third mate gave the rudder order when he visually confirmed that the Busby Island Light was abeam to port. However, prior to the visual confirmation of the vessel’s position, the third mate was required to fix the vessel’s position to confirm any shift to port or starboard. Parallel indexing is one effective method to perform this confirmation.
- Confirmation of the rudder angle
One of the most important duties of the deck officer (and helmsman) is to use the rudder angle indicator to confirm that the rudder has been operated as instructed when changing the rudder’s position. Even on modern ships with high-tech navigation instruments, this confirmation is a golden rule of navigation.
Probable causes determined by the NTSB and recommendations
1) Probable causes
The NTSB determined that the following items are probable causes of the accident. Although the causes encompass many organizations, the causes are summarized very briefly as follows.
- The failure of the third mate to properly maneuver the vessel because of fatigue and excessive workload.
- The failure of the master to provide a proper navigation watch because of impairment from alcohol.
- The failure of Exxon Shipping Company to provide a fit master and rested and sufficient crew for the Exxon Valdez.
- The lack of an effective Vessel Traffic Service because of inadequate equipment and manning levels, inadequate personnel training, and deficient management oversight.
- The lack of effective pilotage service.
The NTSB issued recommendations to a large number of individuals and organizations involved in order to prevent an accident of this type from happening again. The following five recommendations were submitted to Exxon.
- Eliminate personnel policy, including performance appraisal criteria, that encourage marine employees to work long hours without concern for debilitating fatigue and commensurate reduction in safe of vessel operations.
- Implement manning policies that prevent excessively long working hours for crewmembers during cargo handling operation.
- Implement a written policy forbidding deck offices to share navigation and cargo watch duties on a 6-hours-on, 6-hours-off basis, except in emergency.
- Require that two licensed watch officers be present to conn and navigate vessels in Prince William Sound.
- Implement an alcohol-drug program for seagoing employees and train persons who monitor the alcohol/drug rehabilitation program in recognition of recidivism after treatment.
There were also many recommendations for other organizations.
The following is a list of significant recommendations for reference.
U.S. Coast Guard
- Strictly enforce rules to prevent fatigue and review manning standards.
- Conduct a study concerning the alcohol issues.
- Establish a policy for entering a ship’s position when in narrow channels.
- Improve vessel traffic management centers (manning level, equipment, etc.)
Environmental Protection Agency
- Improve federal level responses to emergencies.
- Improve the decision-making authority of on-scene personnel.
Alaska Regional Response Team, State of Alaska, Valdez Terminal
- Improve measures for preventing accidents.
- Improve equipment for responding to an emergency, and the use of this equipment.
U.S. Geological Survey
- Increase monitoring of the state of the Columbia Glacier.
Department of Transportation
- Perform research concerning workplace environments and the management of personnel.
- Improve inspection regulations for all modes of transportation, including post-accident testing regulations (for alcohol and other items).
Lessons from this accident
An examination of this accident reveals that causes were due to the flaws and negligence of a large number of individuals and organizations.
For the crew of a vessel, there are four main lessons.
- The master should be on the bridge when passing through a narrow channel.
- A passage plan should be prepared and a procedure in place for revising the plan.
- The rudder position must be confirmed after steering order.
- The crew must be well trained in the use of devices concerning the steering system.
“Bridge Team Management” (Nautical Institute), written by Captain A. J. Swift, lists the following eight items as causes of a grounding. All eight of these items apply to the causes of the Exxon Valdez accident.
- Passage plan - failure to prepare a passage plan and enter the course on a chart.
- Monitor of track - proper monitor of the progress based on the planned route.
- Restoration of track - prompt actions to correct deviation from the track.
- Use two methods to fix the vessel’s position - use both visual fix and GPS
- Visual fixing - visually determine the vessel’s position.
- Use echo sounder - assessment of under keel allowance in restricted areas.
- Identification of lights - correct identification of navigation lights, confusion created by mistakes.
- Confirm items to determine: use additional officers, etc. for independent checks. Always in narrow passages or when in doubt use Officers or other personnel to navigate.
There is no time limit on the value and usefulness of lessons learned by seafarers in the past.
- National Traffic Safety Board Marine Accident Report (NTSB/MAR-90/04)
- Bridge Team Management (BTM association, Seizando Shoten)
Captain Hiroshi Sekine
Senior Loss Prevention Executive
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