Fatigue, poor passage plan cited in Quebec bulk carrier groundingOct 3, 2014 12:06 PM
A bulk carrier ran aground in the St. Lawrence River in 2012 because the fatigued pilot did not realize a navigation buoy had been removed for the winter and he missed a course change, the Transportation Safety Board of Canada (TSB) said.
The 606-foot Tundra grounded Nov. 28, 2012, and was refloated Dec. 5. The vessel, with a load of soybeans, sustained minor damage.
In the three days prior to the incident, the pilot had been assigned to pilot two vessels upbound from Trois-Rivieres, Quebec, to Montreal. One assignment was Nov. 25, during his 10 scheduled days off, and the other was Nov. 27, his first day back.
On Nov. 28 at 1430, he was assigned to pilot the Halifax and Hamburg-bound Tundra from the Port of Montreal to Trois-Rivieres. The pilot boarded and the master-pilot exchange took place. The pilot set up his portable pilotage unit and Tundra’s bridge team handed over their passage plan. The pilot’s passage plan was not shared with the bridge team, the TSB investigators said in a May 2014 report.
“The pilot did not use all available resources to safely navigate the vessel,” the report said. “Prior to departure, he had not made himself aware of the status of buoys within his pilotage zone, despite the fact that he was primarily using them to pilot the vessel.
“In addition, the pilot’s passage plan contained intermediate courses that were not marked on the vessel’s passage plan, but the vessel’s passage plan was not verified by the pilot and therefore the discrepancies went unidentified. As the vessel proceeded downriver, there was little communication between the pilot and the other members of the bridge team, who were not informed as to the pilot’s intentions prior to course changes.”
The TSB determined that fatigue was a likely factor in the pilot’s diminished situational awareness at a critical time when a course change was required.
The vessel departed at 1830. At 2148, the vessel was aground. During that time, the pilot used his cellphone for five personal calls and six personal text messages, the TSB said.
The pilot was sitting on the port side approximately 26 feet from the rest of the bridge team. As the vessel approached the planned intermediate course change, the pilot could not see the next set of range lights.
The pilot intended to make the course change when buoy S-140 was abaft of the vessel, but the buoy had been removed seven days earlier and the turn was not initiated. The next lateral buoy visible on the vessel’s port side was the S-136, but its lights differed from those of S-140.
“It is unlikely that the pilot missed the course change because he had confused these two buoys,” the TSB concluded. “Rather, it is more likely that the pilot’s ineffective monitoring of the vessel’s position at this time was due to diminished situational awareness resulting from fatigue. Given that the monitoring by the officer of the watch (OOW) was also ineffective, the vessel continued on its course, exited the channel and ran aground.”
It was noted that in 2008, the pilot received two separate 30-day administrative license suspensions that led to two driving under the influence (DUI) convictions under the Criminal Code. These convictions were not required to be reported under current legislation.
The TSB said that without a shared understanding of a vessel’s intended route, progress may be compromised. The findings noted that 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.
The TSB found deficiencies in Canadian pilotage authorities’ policies on DUI convictions and personal communication device use.
Cyprus-flagged Tundra is a 19,814-gt bulk carrier built in 2009 at Weihai Shipyard, China. With 19,533 metric tons of soybeans on board, the ship had a forward draft of 27.4 feet and an aft draft of 27.5 feet. It is powered by one six-cylinder diesel engine generating 7,200 kW driving a single fixed propeller.
Tundra is owned by Prehniet Beheer BV of Geldrop, Netherlands. The vessel is managed by S.A. Navarone of Amaroussion, Greece. The owner sent a message addressed to the entire fleet to remind officers of the watch to regularly verify and monitor the vessel’s course when the vessel is under the conduct of a pilot.
The Laurentian Pilotage Authority (LPA) and the Corporation des Pilotes du Saint Laurent Central (CPSLC) agreed to undertake a study on the risks related to fatigue.
In addition, the LPA, in collaboration with the CPSLC and the Corporation of Lower St. Lawrence Pilots, published a brochure on the master-pilot exchange.