Breakdowns In Situational awareness & Communications Lead Accident

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The Transportation Safety Board of Canada (TSB) today released its investigation report (M19P0057) on the 2019 striking of the anchored bulk carrier Pan Acacia by the bulk carrier Caravos Harmony in Vancouver Harbour, British Columbia.

Incident

On 17 March 2019, the bulk carrier, under the conduct of a pilot, with 22 people on board, struck the anchored bulk carrier while proceeding to anchorage D in Vancouver Harbour, British Columbia. Both vessels sustained damage. No pollution or injuries were reported.

Bulk carrier entered First Narrows, the strong current and eddies caused the vessel to sheer to port. The pilot gave full ahead and starboard helm orders in an attempt to correct the vessel’s course, but engine orders were ineffective and the vessel continued moving to port. 

The pilot then ordered the starboard anchor to be released so that the vessel would swing to starboard. However, neither of the anchors had been prepared for deployment as requested by the pilot, and the starboard anchor was stuck in the stowed position and could not be released. 

With only the port anchor available and having a differing understanding of the situation from that of the pilot, the master ordered the port anchor to be dropped with the aim of bringing the vessel to a stop. This caused the vessel to move further to port. Shortly thereafter, the bulk carrier struck the anchored bulk carrier.

Investigation 

During investigation, it was found that

  • The investigation also determined that communication breakdowns impacted the team’s situational awareness and resulted in different understandings of the emerging circumstances. 
  • During the occurrence, the pilot and bridge crew did not share critical information to build a common and accurate understanding of the situation and this impeded timely and effective coordination of actions to safely manoeuvre the vessel and avoid the striking.
  • Familiarization on essential shipboard machinery and equipment is not effective and if necessary instruction manuals and vessel-specific procedures and training are not provided, the crew may not be proficient in the use of the equipment, increasing the risk of accident or injury.

Lesson learnt

  • Additional training and familiarization must be provided before boarding.
  • Must have good communication and situational awareness.
  • Must conduct a risk assessment on loaded bulk carriers entering Harbour on a strong flood tide and implement additional measures to mitigate the risk of a similar occurrence.

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Source: tsb.gc.ac

 

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