Crew fatigue led to the grounding of an oil tanker in northern Canada when a helmsman repeatedly turned the ship in the opposite direction of the master’s orders, according to the Transportation Safety Board of Canada (TSB).
Nanny, a 360-foot, 6,544- gross-ton oil and chemical tanker owned by Coastal Shipping Ltd., ran aground Oct. 14, 2014. The Canadian-flagged ship was engaged in regular seasonal fueling operations at Baker Lake at the end of Chesterfield Inlet near Hudson Bay.
The vessel was outbound and heading downstream in darkness in the confined waters of Chesterfield Inlet when, to initiate a large course alteration, the master ordered the helmsman to apply port rudder.
The TSB report found that the helmsman repeated the port order but put the helm to starboard. The master continued to monitor the vessel’s progress on the radar. Within seconds of the initial port order, the master issued a larger port helm order because the vessel was not responding as he expected. The master then ordered port helm two more times, and the helmsman continued to apply starboard helm until, 51 seconds after the initial port order, the helmsman stated that the helm was to starboard and applied the correct port order, which stopped the vessel’s rate of turn to starboard 28 seconds later.
Meanwhile, the officer of the watch (OOW) who had passed the con to the master for the significant course change was not assisting the master in navigation, nor was he asked to do so following the change of con, the investigators wrote. Neither he nor the master noticed the error in the direction of the helm applied, nor did they acknowledge the helmsman when he stated that the helm had been to starboard.
The TSB probe found evidence of ineffective fatigue management on the vessel. The master had been awake since 1700 the previous day — a total of 13.5 hours. In the 24-hour period before the grounding, he had a three-hour nap. In the 24 hours before that, he had one four-hour nap following a period of continuous wakefulness of 17 hours. The day before that, he had a period of 22 hours of continuous wakefulness.
In the week before the incident, the helmsman had worked 106 hours, with only 62 scheduled hours of rest. Three days before the grounding, he received only two rest periods of four hours each, the report said.
“At the time of the occurrence, the master and the helmsman were fatigued,” the investigators wrote. “Both were subject to significant fatigue risk factors and both exhibited performance decrements consistent with fatigue, contributing to the bottom contact.”
Over the next three minutes and 24 seconds, the master continued to issue orders for maximum port helm in an attempt to bring the vessel back to the original course despite the limited sea room available. He applied astern propulsion, but the strong tide and the vessel’s speed did not allow enough time to prevent Nanny from touching bottom at Deer Island, four minutes and 43 seconds after the initial course alteration order.
An inspection found that the vessel had sustained damage to the tank plating and internal structures in way of the double-bottom water ballast tanks.
The TSB noted that the OOW ceased participating in the monitoring of the vessel’s progress after the master took over the con. The OOW was not in a position to readily detect the helm error or to assist the master in responding to it. The navigation procedures used by the bridge team members were not adequate to effectively navigate the vessel, the report said.
The TSB wrote that if marine regulations do not require companies to develop comprehensive fatigue management plans, performance deterioration may occur in those who occupy safety-critical positions.
“Until such time as training and continued proficiency in the principles of bridge resource management for all bridge officers are required, there is an increased risk that bridge team awareness and effectiveness will be impaired, thereby increasing the risk to the vessel, its complement and the environment,” the report stated.
Following the grounding, Coastal Shipping sent a memo to all vessels requiring bridge officers to keep the deck log up to date on an hourly basis. The company said OOWs should remain vigilant and aware even when the master is on the bridge and has the con. All crew must adhere strictly to the rest hours, and masters must submit the rest hours to the human resources department on a monthly basis.
The company directed masters to request stoppage from the office to allow for crew rest if a rest-hour breach is present or anticipated. It instructed all crew to view a fatigue management video. Masters were ordered to forward the signed-off certificate for the review of the video at the first opportunity.
Craig Farrell, marine superintendent for Coastal Shipping, told Professional Mariner that the company had provided input to the TSB on the draft report and would provide no further comment.