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TSB: Improperly installed tiller lever key factor in Quebec grounding

Aug 29, 2017 01:04 PM
The TSB accident report includes this schematic of MSC Monica’s non-follow-up tiller operation. “The NFU tiller was connected to the control system in an inverted manner; as a result, the red/green color code operated in contradiction to international standards,” investigators said.

Courtesy TSB

The TSB accident report includes this schematic of MSC Monica’s non-follow-up tiller operation. “The NFU tiller was connected to the control system in an inverted manner; as a result, the red/green color code operated in contradiction to international standards,” investigators said.

A containership veered off course and grounded in the St. Lawrence River due to the helm likely being inadvertently placed 10 degrees to starboard, an unconventionally installed tiller lever, and ambiguity in the verbal exchange between the pilot and the helmsman.

Those were the findings of a report by Canada’s Transportation Safety Board (TSB) into an incident that occurred on Jan. 22, 2016, as the 796-foot MSC Monica was en route from Montreal to Saint John, New Brunswick.

At approximately 0615, the regular change of pilots occurred off Trois-Rivieres, Quebec, with two pilots from the Corporation des Pilotes du St-Laurent central boarding the vessel. A formal master/pilot exchange was conducted. During this exchange, both pilots acknowledged the content of the pilot card while the master briefed them on the vessel’s particulars and maneuvering characteristics. The pilots and master also discussed the voyage plan up the river toward the next change of pilots, which was to occur off Quebec City.

The investigation into the grounding revealed that upon boarding, the two pilots were not familiarized with the use and operation of the unconventional steering system controls.

“They were unaware that the NFU (non-follow-up) tiller was installed in the inverse position, that the red/green indicating disc was inverted, and that the switch was incorrectly connected to the steering gear control system, contrary to the technical specifications set out by the system manufacturer,” the report stated. “The crew of MSC Monica, meanwhile, was aware of the particular configuration of the NFU tiller.”

Subsequently, when the helmsman accidentally turned the helm to starboard and one of the pilots acted to correct the error, he turned the vessel’s heading in the wrong direction, increasing the error. “Pilot No. 1 thus unintentionally applied a helm order of hard-a-starboard instead of hard-a-port,” the report said.

MSC Monica ran aground one nautical mile north-northeast of Deschaillons-sur-Saint-Laurent, Quebec. It was refloated the following day with the assistance of three tugboats and proceeded to Quebec City to undergo the necessary inspections. The vessel sustained minor damage to its hull and major damage to the propeller. There were no injuries or pollution reported.

The investigation also found that when MSC Monica unexpectedly veered to starboard, ambiguity in the wording of the verbal exchange between pilot No. 2 and the helmsman led the pilots and the officer of the watch to incorrectly conclude that there was a steering gear failure.

The TSB said the officer of the watch applied a hard-to-port course correction, but this action was delayed. As a result, the speed of the vessel was not reduced and it exited the channel, subsequently grounding. Post-accident examinations revealed no malfunction with the vessel’s steering gear system.

In addition, the TSB said a delay in ordering the main engine full astern precluded the bridge team from deploying the anchors to prevent the grounding or to decrease the damage to the vessel with a reduced speed at impact.

MSC Monica is owned by Compania Naviera Monica S.A. of Panama and managed by Mediterranean Shipping Co. (MSC) Ship Management Ltd. of Cyprus.

In the fall of 2016, MSC had several of the ship’s steering components overhauled or replaced, including the helm, autopilot, gyrocompass and its repeater. The NFU tiller arm was correctly reinstalled with the longer end pointing toward the stern of the vessel according to the manufacturer’s recommendations, and proper instructions were posted. The owners also verified that all of MSC Monica’s sister vessels had the NFU tiller properly installed.

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