The following is the text of a news release from the Transportation Safety Board of Canada (TSB):
(QUEBEC CITY) — In its investigation report (M14C0219) released Monday, the Transportation Safety Board of Canada determined that fatigue contributed to helm orders being incorrectly applied, causing Nanny to make bottom contact in Chesterfield Inlet, Nunavut. No pollution or injuries were reported, but there was damage to the vessel’s ballast tanks, including a crack that allowed water ingress.
On Oct. 14, 2014, the tanker Nanny was outbound in darkness in the confined waters of Chesterfield Inlet after completing refueling operations for the community of Qamani'tuaq (Baker Lake), Nunavut. To initiate a large course alteration, the master ordered the helmsman to apply port rudder. The helmsman acknowledged the order by repeating it, but turned to starboard instead. Within seconds, 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 later, the helmsman stated the helm was to starboard and applied the correct port order. As the vessel passed its course alteration point, the master took action to slow the vessel down, but the strong tide and the vessel's speed did not allow enough time to prevent Nanny from touching bottom at Deer Island.
Investigators determined that the master and helmsman were fatigued at the time of the occurrence, and that ineffective fatigue management aboard the vessel contributed to their being fatigued while on duty. Neither the master nor the officer of the watch (OOW) noticed the helm direction error, and the OOW had ceased participating in the navigation of the vessel after the master took over, prior to the alteration in course. The investigation also identified deficiencies in the vessel's navigational procedures, and in the application of bridge resource management principles.
Effective safety management requires organizations to identify and manage risks associated with their operations. Despite having a certified and audited safety management system (SMS), the investigation also found several shortcomings with the SMS implementation on board Nanny which contributed to the occurrence. The TSB has identified safety management and oversight as a Watchlist issue. The board is calling on Transport Canada (TC) to implement regulations requiring all operators in the marine industry to have formal safety management processes and for TC to oversee these companies' safety management processes.
Following the occurrence, the vessel's operator implemented enhanced fatigue management procedures, crew training on fatigue, and improved procedures for navigating in confined waters.
Click here to read the complete report.