On March 24, 1989, after loading oil from the Trans-Alaska pipeline terminal, the Exxon Valdez began transit through Prince William Sound. The vessel was traveling at "all ahead full" outside of all normal traffic lanes when it struck Bligh Reef. The Coast Guard's Vessel Traffic Center did not provide the Valdez any warning about being outside of the traffic lanes, as it had lost the vessel on radar and did not follow the procedures for a vessel outside of the lanes. 

The Third Mate, who was responsible for the navigation watch at the time of incident, plotted the ship's position incorrectly and because no other crew members were available, the plotting and navigation error went unchecked. 

It's unclear why the vessel was continuing to transit at "all ahead full" during a period of difficult navigation. It is clear that the crew of the Valdez suffered from fatigue and that crucial management system failures contributed to the grounding.

Management System Failures - System, Procedures and Administrative Controls Inadequacy

• The absence of a fatigue management procedure and appropriate crew numbers meant that the officers routinely worked excessive hours and experienced fatigue on watch. Fatigue of the 3rd mate was cited as a contributing factor to the plotting error in the incident.
• While it was routine for vessels to navigate outside of normal traffic lanes to avoid ice in the area, the procedure for the departure from traffic lanes was not followed on the night of the incident.

Equipment Difficulty – Radar System Design Inadequate

• The Coast Guard Vessel Traffic Center (VTC) did not provide a warning to VALDEZ because they did not plot the vessel positions. Despite vessels routinely departing traffic lanes for ice avoidance, radar coverage in the area only monitored approved traffic lanes, therefore the Coast Guard could not monitor the Exxon Valdez or provide warning to alter course. 

Work Direction – Inadequate Supervision During Work

• The Captain, who tested positive for having alcohol in his system at the time of the incident, was not on watch when the vessel ran aground. The official investigation report found that the master did not provide sufficient supervision of the 3^rd mate at the time if the incident.

As a noted response from the incident, the introduction of management systems occurred quickly throughout the energy industry and became the norm for manaing and assuring operational intgrity of oil and gas operations.