Take one fatigued pilot, add cultural power distance, loss of situational awareness, a dash of unimplemented Bridge Resource Management , inadequate master-pilot exchange and passage planning and there’s a very good change of something unpleasant happening. TSB Canada’s investigation report into grounding of the bulker Tundra off Sainte Anne-de-Sorel, Quebec, is an interesting collection of what-not-to-does.
Groundings in which pilots are involved are among the most expensive. A study by the International Group of P&I Clubs estimated that although groundings only account for 3 per cent of incidents resulting insurance claims of more than $100,000 they accounted for 35 per cent of the cost of claims at a cost of $7.85m for each incident. That compares with collisions, which accounted for 24 per cent of incidents and costs, and fixed and floating object claims which accounted for 64 per cent of incidents but 33 per cent of claims.
There’s money in them thar ills.
When the pilot boarded the Tundra he did not have up-to-date information regarding the buoys he intended to use for navigation. One buoy has been removed, which was not necessarily going to be problem since the next buoy had distinctly different characteristics than the missing device and the pilot would have recognised the situation and adjusted accordingly. He did not have a documented passage plan – his was in his laptop.He should have become aware of the missing buoy, where a course change was scheduled. Fatigue may explain the overun. Says the TSB report: “Although an analysis of the pilot’s 72-hour sleep history indicated that he was not suffering from a significant acute or chronic sleep debt at the time of the occurrence, there were other risk factors and indicators of fatigue. The pilot’s untreated obstructive sleep apnea and shift worker disorder likely reduced the quantity and quality of his sleep on the nights leading up to the occurrence, increasing his risk for fatigue. The physical environment of the bridge, which was dark and warm with the presence of monotonous engine noise, and the time of day (evening), would have been conducive to sleep, especially for individuals with sleep disorders.
“As well, his physical location on the bridge reduced his interaction with other crew members and, in the 10 minutes preceding the grounding, the relatively abrupt cessation in his level of activity suggests that the pilot may have experienced a micro-sleep.”
Fatigue may not necessarily be obvious to the rest of the bridge team, and this pilot did not communicate much with the rest of those on the bridge but a sudden and prolonged silence may indicate that the pilot is not as alert as one would wish.
Yet even a sleepy pilot need not have led to the grounding of the vessel had the rest of the bridge team known his intentions, but they did not and did not ask. The pilot’s passage plan called for a course change when the vessel was abaft of the now-missing buoy. The passage plan prepared aboard ship had no course change at that point but did have one for 0.44 nautical miles down river at waypoint 63
Shorty after passing waypoint 63 the helmsman reported that it was difficult to maintained course due to bank effect. At 2145.20 the helmsman reported he could no longer steer. Despite orders from the now alert pilot the vessel grounded within three minutes.
Nobody on the bridge knew about the earlier course change given in the pilot’s passage plan and between that and the one prepared aboard ship. The pilot had simply signed the ship’s passage plan when he came aboard but had not shown his own passage plan or discussed it with the rest of the bridge team. Basically the team did not know what he actually wanted them to do. There was no ‘shared mental model’.
Many’s the time that a pilot comes aboard and others on the bridge who are responsible for navigation sit back and relax and leave it to the pilot. In this case there may have been another factor involved: ‘power distance’. The crew were from Ukraine the pilot a Francophone Canadian. Differences in cultural influence how they interact.
Says theTSB: “Cultural factors can play a role in communication and hence the effectiveness of BRM. “Power distance” refers to the extent to which members of a culture feel comfortable with hierarchy and power imbalance in personal and business relationships. Research has shown that cultures vary in terms of power distance. Compared with low power distance cultures, high power distance cultures are more comfortable with imbalance among their members, which means that people in less powerful positions may be reluctant to question or challenge authority figures. Cultural differences in power distance may contribute to poor communication between marine pilots and bridge teams. The National Transportation Safety Board recommends that a segment on cultural and language differences and their possible influence on mariner performance be
included in the International Maritime Organization IMO’s BRM curricula.”
All in all the simplest lesson is to keep an eye on the pilot and make sure you know what he wants to do with your ship.