Helm’s Wrong Rudder Setting Results in Grounding


Transportation Safety Board of Canada (TSB) reported the investigation summary of the grounding of MSC Monica at Deschaillons-sur-Saint-Laurent, Quebec, in January 2016.

Summary of the Incident

  • On 22 January 2016, the container vessel MSC Monica ran aground on the St. Lawrence River 1 nautical mile north-northeast of Deschaillons-sur-Saint-Laurent, Quebec.
  • The vessel was re-floated the following day with the assistance of 3 tugs and proceeded to Québec, Quebec, to undergo the necessary inspections.
  • The vessel sustained minor damage to the hull and major damage to the 4 propeller blades. There were no injuries, and no pollution was reported.

MSC Monica

The MSC Monica is a double-hulled, gearless, fully cellular container vessel with a capacity of 3424 TEU, including provisions for 198 refrigerated containers.

The vessel is built of steel and has 7 cargo holds sealed by 13 hatch covers. The machinery spaces and accommodations are located 63.4 metres ahead of the stern.

The vessel is propelled by a diesel engine rated at 24 500 kW, directly driving the propeller at a maximum speed of 95 revolutions per minute. The vessel also has a 900 kW electric bow thruster.

The steering gear on the MSC Monica is controlled via a control panel located on the bridge main console. The control panel enables the bridge crew to toggle between the different steering modes: follow-up, non-follow-up (NFU), autopilot, and the port or starboard wing consoles.

Timeline of the Voyage

  • On 22 January 2016, the MSC Monica departed Montréal, Quebec, and navigated the St. Lawrence River downbound towards Saint John, New Brunswick.
  • At approximately 0615, the regular change of pilots off Trois-Rivières, Quebec, occurred, and 2 pilots from the Corporation des pilotes du Saint-Laurent central (CPSLC), Pilot No. 1 and Pilot No. 2, boarded the vessel.
  • A formal master/pilot exchange was conducted; during this exchange both pilots acknowledged the content of the pilot card while the master briefed them on the vessel’s particulars and manoeuvring characteristics.
  • During the exchange, the pilots and master also discussed the voyage plan through the river towards the next change of pilots, which was to occur off Québec, Quebec.
  • The MSC Monica continued down-bound at an average speed of 13.5 knots. At 0724, after the pilots assessed the external conditions such as the visibility and the upbound traffic, the speed was increased.
  • The master left the navigation bridge at 0735. At that time the bridge team consisted of the officer of the watch (OOW), the helmsman, and the 2 pilots.
  • At 0745, Pilot No. 2, who was conning the vessel at the time, altered course from the “Route de l’Anse-des-Grondines” (047°[True – T]) towards the “Route de la Pointe-des-Grondines” (066½°T), and then started veering the vessel towards the “Route de Sainte-Emmélie” (092½°T) using multiple intermediate courses.
  • At 0756, Pilot No. 2 ordered 085°(G) to the helmsman. At 0757:51, the helmsman reported having steadied the vessel at 085°G, and the ROT of the MSC Monica dropped to 0° per minute.
  • At 0758:33, the ROT increased to 12° per minute and the vessel started to veer towards the starboard side. Twenty seconds later, Pilot No. 2 informed Pilot No. 1 that the vessel was changing course without having ordered any alteration.
  • The helmsman then told Pilot No. 2, “not working.” In response, Pilot No. 2 asked “it’s not responding?” to which the helmsman replied, “it’s not.” The speed of the vessel was 16.7 knots at that time.
  • Immediately, Pilot No. 1 gave the order “follow-up” to the crew, which he repeated 7 times. Meanwhile, Pilot No. 2 ordered the OOW to call the master and the engine room to report the failure of the steering gear.
  • As the vessel was already in follow-up mode, no action was taken. Instead, the OOW followed Pilot No. 2’s orders and then activated the general alarm bell.
  • At 0759:29, Pilot No. 1 moved to the conning station and operated the steering mode control switch directly, in order to change from follow-up to NFU mode, while the OOW said to Pilot No. 1 “this is non-follow-up, Sir.”
  • Pilot No. 1 then activated the handle of the NFU tiller. The ROT increased, peaking at 36.4° per minute, and the vessel accentuated its sheer to the starboard side.
  • At 0759:40, Pilot No. 1 ordered “hard to port” and, at 0759:45, he ordered the main engine to be stopped.
  • At 0759:53, Pilot No. 1 ordered “emergency” and, at 0800:11, he reported to the master, who had just arrived on the navigation bridge, that they had “completely lost the steering” and that the vessel was going aground.
  • At the same time, the chief engineer, who had just arrived in the engine control room, observed that the rudder angle indicator was at 35° to starboard (hard-a-starboard).
  • At 0800:29, as the vessel was exiting the navigation channel, the OOW noticed that the rudder was positioned hard-a-starboard and brought the handle of the NFU tiller to the left.
  • At 0800:54 Pilot No. 2 mentioned to Pilot No. 1 that the vessel was “far outside“. At 0800:55, Pilot No. 1 called the Québec Marine Communications and Traffic Services (MCTS) on the VHF radiotelephone and reported that the vessel had lost its steering capability.
  • At 0801:18, as the MSC Monica’s speed had diminished to 10 knots, Pilot No. 1 ordered the main engine to full astern. At 0801:26, the vessel started to veer to port.
  • At 0801:54, Pilot No. 1 asked the master not to drop anchor as it was too late to prevent the vessel from running aground.
  • At 0802:03, the vessel went aground on the south side of the river, just east of Deschaillons-sur-Saint-Laurent, Quebec. The master stopped the main engine 13 seconds after the vessel had been immobilized.
  • At 0809:40, as the tide was ebbing, an initial attempt was made to free the MSC Monica and the main engine was put to full astern for 5 minutes. After the pilots confirmed that the vessel was not moving, the engine was ordered to a stop.

On 23 January 2016, at 0730, Pilot No. 1 and Pilot No. 2 were relieved from duty by 2 other pilots from the CPSLC.

The MSC Monica was refloated with the assistance of 3 tugs during the flooding tide at 1918 that evening and was escorted to the safe anchorage zone off Grondines, Quebec.

In the morning of 24 January 2016, the vessel weighed anchor and proceeded downstream, under a tug escort, towards Québec, where it moored at 1211.

Before the vessel’s departure from Québec, the crew modified the NFU tiller display: they removed the translucent plastic disc attached to its base and posted colour‑coded labels (red with the word “PORT” and green with “STBD,” the abbreviation for starboard) on either side of the NFU tiller.

Damage to the vessel

The vessel sustained major damage to the 4 propeller blades.

The vessel’s structure was also damaged in way of the starboard ballast water tank No. 3, where the shell plating and web frames 82, 83, 84, and 85 were distorted between the tank top and the first stringer.

The port bilge keel was distorted, while the starboard side of the rudder, both sides of the bow, and the entire port-side length of the hull sustained minor damage consisting of scratches on the hull coating and shell plating.

Factors leading to the grounding

While navigating the St. Lawrence River downbound, the MSC Monica unexpectedly veered to starboard, exited the buoyed channel, and ran aground.

Testing and examinations established that the steering gear and its control system were fully functional and that no steering failure occurred.

The winds and current were not strong enough to cause the vessel’s path to change, and the vessel’s speed was not excessive for this particular type of vessel in this section of the river.

The Centre for Marine Simulation (CMS) simulator was used to reproduce several scenarios under the same conditions at the time of the occurrence. The results demonstrated that the most plausible scenario for causing the vessel to initiate a veering to starboard with a rate-of-turn (ROT) of 12° per minute was that the helm was originally positioned at 10° to starboard, while the course had to be maintained at 085°gyro (G).

The helmsman at the time had the expectation that the helm was positioned at 10° to port. Because the intent was to maintain the course and not veer to starboard, the initial deviation from the course was due to the helm likely being inadvertently placed 10° to starboard.

The pilots and the officer of the watch (OOW) concluded that the steering gear had failed based on their interpretation of the helmsman’s responses.

Steering gear and control system

NFU tiller controls and displays vary between vessels and manufacturers.

The various classification societies have specific rules with regard to bridge design ergonomics, and there are multiple organizations, that issue standards specifying the exact design requirements for these controls and displays.

Although the designs of NFU tillers vary, internationally recognized maritime standards designate the colour red to signify port, while the colour green signifies starboard.

On the MSC Monica, the tiller had been installed in the inverse position, contrary to the technical specifications set out by the system manufacturer of the system and the international standards for colour signification.

When the tiller on the MSC Monica was moved to the left, for example, the green part of the indicating disc was illuminated and the steering gear moved the rudder to the port side.

If the ergonomics of critical shipboard equipment, such as an NFU tiller, are designed in a way that is confusing or contradicts expectations, there is a risk that a user who is unfamiliar with their configuration will operate them incorrectly.

Pilots directly handling controls

Pilots are legally empowered to operate the equipment directly, and, according to the Canadian Marine Pilots Association (CMPA), pilots are not only allowed to, but must intervene in an emergency situation, should it be deemed necessary by the pilots.

However, some pilotage corporations issue policies that recommend against this, as there are advantages to the separate roles taken by the crew and the pilot in navigation.

Because controls and displays of critical shipboard equipment can vary widely, operators have to be trained on or at least familiarized with the use and operation of each specific arrangement to reduce the risks of incorrect use.

Bridge team communication

As demonstrated by this occurrence and previous TSB investigations, there continue to be language barriers that can be problematic on board foreign-registered vessels.

Not only can language barriers inhibit communication, but also cultural differences may affect relationships among the bridge team members.

Language and cultural differences may have contributed to the challenges in bridge team communication on the MSC Monica. Because Indian cultures tend to be higher on the power‑distance dimension than Western cultures.

If bridge team members do not share a complete and common understanding of an emerging problem and continuously exchange information to solve problems, there is a risk that the bridge team’s response will be premature, uncoordinated, and ineffective.

Findings as to cause and contributing factors

  • The MSC Monica unexpectedly veered off course to starboard due to the helm likely being inadvertently placed 10° to starboard.
  • The ambiguity in the wording of the verbal exchange between Pilot No. 2 and the helmsman led the pilots and the officer of the watch to incorrectly conclude that there was a steering gear failure.
  • No immediate action was taken by the bridge team to verify the functionality of the steering gear once a system failure was assumed.
  • The crew did not switch to non-follow-up mode because Pilot No. 1 mistakenly issued the contradictory order to switch to follow-up mode.
  • Pilot No. 1 directly handled the manoeuvring equipment to switch the steering to non-follow-up mode.
  • The non-follow-up tiller was not installed in accordance with the manufacturer’s specifications, nor was it installed consistently with internationally accepted standards.
  • Because Pilot No. 1 was unfamiliar with the particular ergonomics of the non-follow-up tiller as it was installed on the vessel, he unintentionally applied the helm order hard-a-starboard instead of hard-a-port.
  • Although the officer of the watch applied a hard-a-port rudder correction, this action was delayed. As a result, the speed of the vessel was not reduced and the vessel exited the buoyed channel and subsequently ran aground.
  • The delay in ordering the main engine to be put to full astern precluded the bridge team from the possibility of deploying the anchors to prevent the grounding or to decrease the damage to the vessel with a reduced speed at impact.

Findings as to risk

  • If the ergonomics of critical shipboard equipment, such as a non-follow-up tiller, are designed in a way that is confusing or contradicts expectations, there is a risk that a user who is unfamiliar with their configuration will operate them incorrectly.
  • If marine pilots operate critical shipboard equipment without proper familiarization, there is a risk that the equipment will be operated in an incorrect manner.
  • If bridge team members do not share a complete and common understanding of an emerging problem and continuously exchange information to solve problems, there is a risk that the bridge team’s response will be premature, uncoordinated, and ineffective.

Other findings

  • Some pilots’ associations have policies for their pilots not to directly handle the shipboard controls but to issue verbal orders only, unless warranted by an emergency situation, while others do not have an official position on this matter.

Safety measures

On 02 June 2016, the Transportation Safety Board of Canada sent Marine Safety Advisory (MSA) letter 02/16 to the company that ensures the technical management and operation of the MSC Monica, in order to identify the issues with the configuration of the vessel’s steering gear non-follow-up (NFU) mode controls.

A copy of the letter was also sent to Transport Canada, the vessel’s flag state authority, the classification society ensuring the oversight of the 5 sister vessels, the International Association of Classification Societies, and the manufacturer of the MSC Monica’s steering gear control system.

Following the receipt of MSA letter 02/16 issued from the TSB, the owners of the MSC Monica carried out a thorough assessment of the vessel’s steering gear and control systems.

Although no malfunction was identified, some components were found “fragile.”

Consequently, the owners had several parts either overhauled or replaced during the periodic drydocking of the vessel, which took place in Turkey during the fall of 2016.

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Source: Transportation Safety Board of Canada



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