Canada issues investigation report re grounding of bulk carrier Tundra

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Category: Accidentes
Published on Wednesday, 04 June 2014 02:15
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Safety4Sea 3/06/2014

Lack of communication between pilot and bridge

Bulk-Carrier-TundraThe Transportation Safety Board of Canada (TSB) released an investigation report regarding the grounding of bulk carrier Tundra due to lack of communication between pilot and bridge.

The TSB of Canada found that fatigue and ineffective communication between the pilot and bridge team contributed to the grounding of the bulk carrier Tundra, near Sainte-Anne-de-Sorel, Quebec in November 2012. There were no injuries, but the vessel sustained minor damage.

On 28 November 2012, the Tundra departed Montreal, Quebec under the conduct of a pilot en route to Halifax, Nova Scotia. A master-pilot exchange of vessel technical information took place prior to departure, but passage plans for the voyage were not discussed. That evening, the vessel passed a position where a course alteration is required. However, no orders to change course were given by the pilot. The vessel exited the navigation channel and ran aground.

The investigation found that during the voyage, the pilot and bridge team were not exchanging information regarding navigation and that the bridge team was unaware of a planned course change. The vessel exited the navigation channel and ran aground because the pilot did not make a planned course change. Fatigue was also likely a factor for the pilot at a critical time when the course change was required to maintain safe navigation.

Since the occurrence, the vessel owner reminded its bridge officers to regularly verify and monitor their vessels' position when under the conduct of a pilot. The Laurentian Pilotage Authority and the Corporation des Pilotes du Saint-Laurent Central committed to studying the risks related to fatigue. As well, they published a brochure for pilots to enhance communications between pilots and ship masters.

Report Findings

Findings as to causes and contributing factors

  • The pilot's passage plan was not documented or communicated to the bridge team, nor was the vessel's passage plan verified by the pilot.
  • The pilot and other members of the bridge team were not exchanging information pertaining to the navigation of the vessel; as such, the bridge team was unaware of a planned course change.
  • The pilot did not use all available navigational resources in piloting the vessel.
  • The pilot did not carry out a planned course change and, as a result, the vessel exited the channel and ran aground.
  • Fatigue was a likely factor in the pilot's diminished situational awareness at a critical time when a course change was required.

Findings as to risk

  • If bridge team members do not share a complete and common understanding of a vessel's intended route and continuously exchange information, there is a risk that the bridge team members' ability to monitor a vessel's progress may be compromised.
  • If regular pilot proficiency assessments are not conducted, there is a risk that unsafe pilotage practices may continue unchecked.
  • If pilots are not trained in fatigue awareness, there is a risk that they may not be able to identify symptoms or signs related to sleep disorders that are not detectable through a regular medical exam.
  • If Canadian pilotage authorities do not have a driving under the influence (DUI) reporting policy for licenced/certificated pilots, those experiencing alcohol‑related problems that affect performance may not be identified and treated, increasing the risk of accidents.
  • If pilotage organizations do not institute specific rules or protocols to govern the use of personal communication devices while piloting, pilots may not understand the associated risks and may continue to use them at any time while piloting.

 

For more information read the TSB Marine Investigation Report:

Lack of communication between pilot and bridge team contributed to 2012 grounding of bulk carrier Tundra on the St. Lawrence River