Summary:
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 refloated 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.
Damages:
The MSC Monica 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.
Findings:
- 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.
- 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.
Action Taken:
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.
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Source: Transportation Safety Board of Canada
