The government agency responsible for safety at sea (MCA) failed to detect issues with voyage planning that led to a serious crash involving the ferry currently commissioned by Scots ministers as an emergency vessel for lifeline ferry services.

It comes as investigators found that Orkney Islands Council Harbour Authority was found to have repeatedly failed to spot that MV Alfred had been routinely passing too close to land - before it crashed causing injuries to 41 passengers and crew, The Herald can reveal.

Ten people suffered serious injuries that meant they were unable to work for 72 hours or more in the wake of the crash off Swona, the uninhabited privately owned island in the Pentland Firth off the north coast of Scotland which is part of the Orkney archipelago.

The Marine Accident Investigation Branch (MAIB) found that a master of the Pentland Ferries vessel, MV Alfred, had "almost certainly" fallen asleep a matter of seconds before it crashed in July, 2022.

The investigation also identified that Alfred’s passage plan was inadequate and that its Electronic Chart Display Information System, which was the ferry’s primary means of navigation, was not being used effectively to support safe navigation and warn of danger.

READ MORE: Scots £1m-a-month emergency ferry previously crashed after master fell asleep

MV Alfred, once described as the most environmentally friendly ferry in Scotland, had 84 passengers and 13 crew on board when it partially ran aground on the Isle of Swona, the more northerly of two islands in the Pentland Firth between the Orkney Islands and Caithness on the Scottish mainland.

RNLI lifeboats were called to evacuate the Vietnam-built £14m catamaran – with one person being rushed to hospital with a fractured shoulder.

The Herald: MV Alfred

Dozens were feared to have suffered mental trauma and physical injuries including fractures, sprains and soft tissue damage.

CCTV imagery showed passengers and crew being violently thrown to the deck and others somersaulting over benches.

The ferry has since been brought in by Transport Scotland as an 'emergency vessel from April 2023 with Pentland Ferries operating the services on behalf of the state-owned ferry company CalMac.

But it has emerged that the MAIB was also concerned that among the safety issues the accident raised included that it was allowed to "routinely" pass too close to land.

It said that the vessel master's "significant experience" on the route and the highly repetitive nature of Alfred’s schedule between Gills Bay and St Margaret’s Hope "had probably desensitised him to the risks of transiting close to the shore".

And the MAIB found that the vessel's "inadequate passage plan" had been in place since Alfred entered service in 2019, it was a "significant safety issue" that went "undetected" by annual company audits and surveys by the Maritime and Coastguard Agency, the publicly funded official UK Government agency responsible for safety at sea.

The MAIB said that "given that passage planning and the correct operation of bridge equipment are critical to the safe operation of every vessel, it is essential that these are subject to assurance during the survey and audit processes".

The MAIB say that it was not until the MCA’s post-accident general inspection that the vessel’s passage planning and other issues "were found to be deficient".

MV Alfred on a recent return to Troon

In the wake of the crash, they issued a "major non-conformity because the Pentland Ferries safety management procedures for bridge manning and passage planning were not being followed.

Orkney Islands Council Harbour Authority, which is responsible for safety in the harbour area, created what are described as vessel traffic services (VTS) guard zones just over half a mile from the coast around the islands of Stroma and Swona.

The purpose of a VTS is to "contribute to the safety of life at sea", improve the efficiency of vessel navigation and mitigate the development of "unsafe situations" through providing timely and relevant information that may influence ship movements and assist onboard decision-making. It is also there to monitor and manage ship traffic to "ensure the safety and efficiency of vessel movements.

The system automatically alerts the VTS operator of a vessel entering the zone.

According to investigators, the system gives the operator the chance to warn the vessel’s crew of the development of what it called "unsafe situations".

And according to the MAIB, MV Alfred’s track "routinely triggered" the VTS guard zones around the islands of Stroma and Swona.

It did too before the crash, but the VTS operators did not call the ferry.

The MAIB said that the harbour authority's VTS was not monitoring the movement of the ferry and did not raise the alarm when it entered the danger zone.

MV Alfred had entered the Orkney authority's waters two minutes before it ran aground.

Investigators say the VTS operators were aware that Alfred’s master "routinely" entered the guard zone but viewed it as "low risk" and "did not monitor the navigational safety of the ferry’s passage through their area".

"It is therefore unsurprising that the VTS operators did not warn Alfred’s master that he was entering the Swona guard zone on the day of the accident," said an investigation analysis. "Given that this guard zone is not marked on the navigational chart or referred to within the port’s passage plan, it is possible the master was unaware he had entered the zone.

The Herald:

"However, if the VTS operators had challenged Alfred’s master... they may have alerted him to the risk he was taking, and possibly prevented the vessel grounding.

Alfred’s master had held a Pilotage Exemption Certificate (PEC) since 2004. This meant he fulfilled certain criteria showing a capacity to safely manage his vessel in the waters in question.

But the MAIB say that while a 2019 revalidation involved a licensed harbour pilot observing the master’s performance, it did not include an assessment of the passage plan or review his past navigational tracks.

"The opportunity to remind the master to keep Alfred clear of the Swona guard zone was therefore missed," they said.

The MAIB said that the master's PEC was suspended following the crash and that the harbour authority had taken action to "improve its oversight" of ferry operations in its waters.

Meanwhile it recommended that the MCA direct its surveyors to ensure that vessel passage plans are available.

The investigation into the crash found the master's sleeping went unnoticed, and he was neither awoken nor alerted because there was no bridge lookout and the BNWAS (Bridge Navigational Watch Alarm System) was switched off.

The investigators also found that despite the vessel being aground for over an hour neither the crew nor the Pentland Ferries ERT (emergency response team) sought to obtain a nominal list of people on board, their injuries, or whether they had been evacuated to the lifeboat.

And the MAIB said the number and severity of injuries suffered by Alfred’s passengers and crew was almost certainly increased because they were not warned to brace for impact before the vessel grounded at a speed.

An Orkney Council spokesman said: "We’ve considered and accepted the findings of the MAIB investigation. Since the grounding incident, a number of improvements have been implemented, including improved communication with all local ferry companies on their passage plans , an improved auditing process around this and an improved PEC revalidation process."

Pentland Ferries said it welcomed the investigation report and was continuing to digest its contents.

Managing director, Helen Inkster, said:  “We stand by the premise of the report, which is not to assign blame or liability, but rather to ensure future accidents across the marine industry are prevented. 

“While we will never be complacent, we are satisfied that all the actions that could be taken by Pentland Ferries to ensure passenger safety have already been taken.  We will always ensure that our vessels have detailed procedural plans, the right people, and rigorous training regimes in place.”

The MCA was approached for comment.