B SAFE Seafarer Health BSAFE INCIDENT CASE STUDY 26: CREW FATIGUE CAUSED GROUNDING OF SHIP ON THE BULGARIAN COAST Published: 12 February 2025 ON 20 SEPTEMBER 2021, A GENERAL CARGO SHIP RAN AGROUND ON THE ROCKY COAST OF THE YAILATA PROTECTED AREA IN BULGARIA. THE INCIDENT OCCURRED WHEN THE SHIP, TRAVELING FROM YUZHNIY, UKRAINE, TO VARNA, BULGARIA, DEVIATED FROM ITS PLANNED COURSE BECAUSE THE SECOND OFFICER (2/O) ON WATCH FELL ASLEEP. THE BRIDGE NAVIGATIONAL WATCH ALARM SYSTEM (BNWAS) WAS FOUND DEACTIVATED, REMOVING A CRITICAL SAFETY NET. THE INVESTIGATION BY THE BULGARIAN NATIONAL AIR, MARITIME, AND RAIL ACCIDENT INVESTIGATION BOARD (NAMRAIB) CONCLUDED THAT FATIGUE, INSUFFICIENT LOOKOUT ARRANGEMENTS, AND LAPSES IN THE SHIPS SAFETY MANAGEMENT SYSTEM (SMS) CONTRIBUTED SIGNIFICANTLY TO THE INCIDENT. THIS CASE STUDY EXAMINES THE EVENT, THE DAMAGE INCURRED, AND THE LESSONS LEARNED TO IMPROVE SAFETY PROTOCOLS AND PREVENT SIMILAR ACCIDENTS IN THE FUTURE. Figure 1 Grounded Ship Source Republic of Bulgaria NAMRAIB INCIDENT OVERVIEW BACKGROUND OF SHIP AND VOYAGE DETAILS The 1,984 gt ship, built in 1989, is registered under the Panamanian flag and has an overall length of 89.21m. The ship departed from Yuzhniy, Ukraine, on 18 September 2021, carrying a cargo of 2,837 metric tons of urea fertiliser. As the ship proceeded towards its destination in Varna, Bulgaria, it was expected to follow a Traffic Separation Scheme (TSS) in Bulgarian waters, designed to enhance navigational safety in congested areas near the shore. SUMMARY OF THE INCIDENT At midnight on 20 September 2021, the 2/O relieved the master to take over the 0000 to 0400 navigational watch. However, contrary to the SMS and international regulations, no additional lookout was assigned for the night watch. The BNWAS, designed to alert the crew if the officer on watch becomes incapacitated, was turned off. During the night, the ship proceeded on autopilot. The 2/O conducted his watch normally. However, between 0345 and 03