The following is the text of a news release from the Transportation Safety Board of Canada:
(GATINEAU, Quebec) (Dec. 10) — The Transportation Safety Board of Canada today released its investigation report (M13C0071) into the striking and subsequent grounding of the cargo ship Claude A. Desgagnes in the St. Lawrence Seaway near Iroquois, Ontario, on Nov. 6, 2013.
The investigation found that, as the vessel proceeded downriver, the pilot and master of the Claude A. Desgagnes disagreed on maneuvers to use while approaching the Iroquois Lock. They both knew that the vessel's speed of approach needed to be reduced; however, each thought that a different method was the best way to slow the vessel. As a result, the vessel was not slowed by any means, continued on its path and struck the Iroquois Lock upper approach wall. Following the striking, they attempted to realign the vessel, but they were unable to regain control. The vessel crossed the channel and ran aground.
Although normal procedures state that the pilot issues orders and advises the master, the master is ultimately responsible for the safety of the vessel and for all decisions made, including which orders to enact.
The challenge in crew communications found in this occurrence is consistent with the findings of TSB's safety issues investigation (SII) of 1995: “A Safety Study of the Operational Relationship between Ship Masters/Watchkeeping Officers and Marine Pilots.” The SII determined that misunderstandings between masters and pilots, often caused by a lack of adequate communication, were a significant factor in many marine occurrences involving piloted vessels.
After this occurrence, the owner, Transport Desgagnés Inc., revised and updated its bridge manual instructions.
To view the complete report, click here.
