Dec 162014

TSB’s report on the contact and grounding incident involving the general cargo vessel Claude A. Desgagnes as it entered Iroquois Lock in the St. Lawrence Seaway, is a tale of sticky decisions, poor communications and whose-in-charge confusion. One lesson is that once you’ve made a decision, keep in constantly under review.

Here’s the short version:

As the vessel proceeded downriver, the master and pilot spoke, but did not develop a shared understanding of the manoeuvre to be used in the approach to the Iroquois Lock. While the pilot had explained his plan to dredge the anchor to the officer of the watch (OOW) earlier in the voyage, the details of the plan were not relayed to the master when he arrived on the bridge.

Although the pilot later informed the master of his intention to carry out the manoeuvre in broad terms, the master did not confirm that he understood or agreed with the manoeuvre. Neither the master nor the pilot discussed the plan further as the vessel approached the lock entrance. When the master ordered that the vessel’s speed be reduced, the pilot advised against this due to the direction and force of the current at that time. Although the pilot requested the forward anchors be deployed, each time, the master declined.

When the vessel reached a critical point, close to the lock, the pilot once more requested the use of the anchor to slow down the vessel, but the master did not initiate the pilot’s orders. The anchor was not dredged, nor was any other means of slowing down the vessel employed; therefore the vessel continued on its path and struck the upper approach wall. Following the striking, the master and pilot attempted to realign the vessel; however, they were unable to regain control due to the vessel’s momentum, the wind, and the current. The vessel crossed the channel and ran aground.

One of the key decisions that had to be made was how to approach the lock wall. The pilot’s proposal to dredge the anchor as a means of slowing down the vessel was based on previous experience of using this method successfully with vessels having similar characteristics. Other factors included time, wind speed and direction, current, and the limited space available with a vessel ahead going through the lock.


Claude A. Desgagnes makes contact and hits the dirt.

However, the master decided that reducing the vessel’s speed using the main engine, instead of dredging the anchor, was the best course of action in the approach. His decision was based on prevailing conditions, his background, and his previous experience. This previous experience included work for a company where anchors were not permitted to be deployed in non-emergency situations or where there was less than a minimum of 3 metes of under-keel clearance.

That company requirement was based on an incident where another company vessel had deployed the anchor in the proximity of a lock but had overridden the anchor, causing damage to the vessel.

As we all know the master remains responsible for the safety of the vessel and conduct is held to be ‘to master’s orders and to pilot’s advice’.

Confusion reigned at the helm where the man at the wheel had difficulty knowing who had conduct of the vessel. Because the handing over over of the con was unclear, even ambiguous, the helmsman was getting orders from the pilot and the master at the same time. For example, as the vessel approached the lock entrance, the pilot requested the use of the starboard anchor in order to slow down the vessel and to dredge to port towards the upper approach wall. The master did not initiate the action. The pilot then told the master to take command and control of the vessel; however, this transfer was not repeated or confirmed. The pilot and master both continued to issue orders to the helmsman, who, at one point, decided to follow the master’s orders. The pilot also issued engine directions to the master, who performed them and repeated them back to the pilot.

Master and pilot exchanges are often though of as the chat that happened when the pilot boards then it’s over. As the TSB report says: “Master and pilot exchanges are a continuous process that starts from an initial, more formal, exchange and extends throughout the duration of the piloted voyage, as needed. Exchanges of information include agreements on plans and procedures, including contingency plans for the anticipated passage and discussions of any special conditions…Insufficient or poor exchanges can result in the bridge team not sharing a common understanding.

In other words, it is more akin to a conversation that ensures that everyone sings from the same song book. That did not happen on the Claude A. Desgagnes. They were not communicating effectively, did not agree on manoeuvres while approaching the lock, and did not discuss in detail their respective plans of action. A common understanding that ensures unity of action is achieved through open and interactive communication: open communication moves to closed-loop communication: Information is given by the issuer, repeated by the receiver, and re-confirmed by the issuer.

The pilot and the master both knew that the vessel’s speed of approach needed to be reduced; however, they each thought that their method was the best way to slow down the vessel in the approach, based on their individual experiences and knowledge. The pilot and master were not communicating with each other in sufficient detail to allow them to achieve a mutual understanding and “close the loop”; this negated timely agreement and optimal decision making. Although there was a formal master-pilot exchange at the beginning of the voyage that employed a detailed checklist, the exchange did not address the dredging manoeuvre that was planned by the pilot to slow down the vessel in this occurrence.

The pilot requested to have the anchor deployed and, each time, the master declined. The master at one point suggested that the speed be reduced using the main engine, but the pilot indicated that the direction and force of the current prevented that manoeuvre.

Misunderstandings between masters and pilots, often caused by a lack of adequate communication, are a significant factor in many marine occurrences involving piloted vessels. If bridge team members do not exchange information in order to achieve a mutual understanding of a vessel’s manoeuvres on an ongoing basis, there is a risk that crucial manoeuvres to ensure safe navigation will not be completed in a timely manner.

Pilot and master had made two separate but incompatible decisions about how to handle entry into the lock but had not actually reviewed those decisions. It’s tempting to make a decision and stick to it regardless but it isn’t always the best thing to do. TSB warns: “Decision making can be defined as a four-step sequence: gathering information, processing that information, making a decision based on possible options, and then acting on that decision. Once a decision has been implemented, the process starts over again as new information is gathered while monitoring the effects of the decision. Decisions can be influenced by a wide range of factors such as individual perception of the situation, experience, training, expectations, time constraints, and contextual elements. Once a decision is made, there is a tendency for an individual to continue with the selected course of action unless there are compelling reasons not to do so. Additionally, people will often seek out elements that reinforce and support, not contradict, the decision that has already been made. Past experience under similar circumstances can make people reluctant to select a different course of action.”

Looking for things that reinforce a decision rather than those that question it is called confirmation bias. It can be a hazardous habit. An as cognitive psychologists tell you, such bias actually effects how we perceived the data we see.

Download TSB Report

TSB report: A Safety Study of the Operational Relationship between Ship Masters/Watchkeeping Officers and Marine Pilots

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