Fatigue, poor communications blamed in bulker grounding

MAY 29, 2014 — In an investigation report (M12L0147) released today, the Transportation Safety Board 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 November 28, 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. Additionally, they published a brochure for pilots to enhance communications between pilots and ship masters.

As usual, the full report contains a lot more disturbing detail than the dry summary issued by the TSB. Here's just one extract:

The pilot on the Tundra was involved in a similar accident in 2004, when the container vessel Horizon grounded at the same location as in this occurrence. In the TSB report that followed, one of the findings as to cause stated that fatigue may have been a factor in the pilot's decreased vigilance at a critical time. As a result of the Horizon grounding, the pilot underwent a sleep evaluation in 2007 at the LPA's request; however, he did not receive any feedback regarding the outcome of that evaluation, nor did the LPA due to patient–physician confidentiality. The diagnosis from the sleep evaluation was that the pilot's sleep was "fragmented by numerous returns to wakefulness, probably compatible with shift worker insomnia." He was not diagnosed with obstructive sleep apnea at that time. The pilot remained in service and subsequent biennial medical examinations required to determine fitness for duty made no mention of a sleep disorder.

At the time of the Tundra's grounding, the pilot had the following risk factors commonly found in obstructive sleep apnea sufferers: elevated body-mass index, use of cigarettes, environmental allergies, asthma, snoring, and previous difficulties with sleep, as well as the demographic risk factor of being middle-aged. The pilot was requested by the TSB to undergo a sleep evaluation, which he did on 30 April 2013. This sleep evaluation included a comprehensive examination of physical features that can contribute to sleep‑disordered breathing. As a result of the 2013 sleep evaluation, the pilot was diagnosed with mild, positional, rapid eye movement‑related obstructive sleep apnea and shift work disorder.

Read the whole report HERE

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